Oregon behavioral health billing for CCOs, commercial plans and Medicare

Our behavioral health billing service is built for Oregon outpatient clinics, private practices, IOP, PHP, MAT, residential and detox programs. We handle claims, authorizations, denials and payer follow up for commercial plans, Medicare and the Oregon Health Plan, where the rules change by CCO.

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What makes Oregon billing different

The rules that decide whether an Oregon claim pays the first time.

Every OHP claim has one right payerMost Oregon Health Plan members are enrolled in a coordinated care organization (CCO), and members who are not in a CCO are billed to OHA fee-for-service. Members move between CCOs and open card coverage, so the payer on the date of service owns the claim. A claim sent to the wrong CCO, or billed fee-for-service for a CCO member, is denied and has to be resubmitted.

CCO claims are due in 120 daysCCO claims must be submitted within 120 days of the date of service under OAR 410-141-3565, and a CCO contract can set a shorter window. OHP fee-for-service claims have 12 months under OAR 410-120-1300. The 365-day CCO exception covers cases like retroactive eligibility, not a provider's failure to check eligibility.

Authorization and the Prioritized ListOutpatient therapy usually needs no prior authorization under OHP, but residential, PHP and, at some CCOs, IOP may need prior authorization or notification. OHP pays only when the diagnosis and procedure pair falls on a covered line of the Prioritized List, which is lines 1 through 470 since February 1, 2026. Members under 21 receive all medically necessary services regardless of line.

Missing SUD modifiersOn OHP fee-for-service claims, most SUD codes, including H0004, H0005 and H0015, require the HF or HG modifier. A claim without one does not match the fee schedule, even when the code is right. Any code billed with the HK modifier always needs prior authorization.

Payers we bill in Oregon

Public and commercial payers, and what matters for behavioral health claims with each.

OHP fee-for-service (OHA)For OHP members not in a CCO. Claims are due within 12 months, and the fee schedule's required modifiers, such as HF and HG, apply.

CareOregonCCO in the Portland metro whose behavioral health credentialing also covers Health Share members. Its 2026 policy pays outpatient mental health and SUD groups that do not qualify for the directed payment 90% of DMAP rates.

Health Share of OregonHas delegated its mental health and substance use network to CareOregon since January 1, 2020, so there is no separate Health Share behavioral health application.

Trillium Community Health PlanTook over Lane County from PacificSource for services from February 1, 2026. Not routinely adding outpatient behavioral health contracts, except for CLSS-certified providers.

PacificSource Community SolutionsCCO in several areas outside the Portland metro and Lane County. Publishes 30 to 90 days for credentialing from a complete application.

RegenceManages behavioral health in-house. Residential and inpatient need prior authorization within 3 business days; PHP and IOP within 7 calendar days of the start.

Moda HealthRequires prior authorization for mental health and SUD residential and PHP, and for mental health IOP. Uses LOCUS and CALOCUS for Oregon plans and ASAM for SUD.

Providence Health PlanWill not offer new commercial plans in 2027, and provider contracts do not change in 2026. One facility form covers inpatient, residential, PHP and IOP authorization.

PacificSource (commercial)IOP needs prior authorization before care starts. Since October 1, 2026, board-registered associates cannot treat or bill its commercial or Medicare members.

Kaiser Permanente NorthwestUses prior or concurrent authorization for inpatient and residential mental health and SUD care.

AetnaBehavioral health runs through Aetna Behavioral Health. Residential and PHP need precertification; IOP has not needed it since 2019.

Cigna (Evernorth)Behavioral health runs through Evernorth, which requires accreditation such as CARF or Joint Commission, or Medicare certification, before it contracts with a residential, PHP or IOP facility.

UnitedHealthcare (Optum)Behavioral health network and authorizations sit with Optum, so a UnitedHealthcare medical contract does not make you in network for behavioral health.

Medicare (Noridian)Noridian is the Medicare contractor. Claims are due within one calendar year of service, and IOP and PHP pay only in certain settings, such as hospital outpatient departments and CMHCs.

What we handle

Billing run by people who have operated treatment programs, inside the EHR you already use.

Eligibility and benefits checked at admission and at every level of care change, including which CCO covers the member
Authorization tracking for CCOs and commercial plans: approvals logged, end dates and review dates watched
Commercial, Medicare and Medicare Advantage, and OHP claims, scrubbed against payer rules before submission
Denials and appeals worked with the clinical record behind them
Payer follow up by phone and portal until paid or appealed
ERA and EOB posting, with underpayments measured against your contract
A monthly written report with aging by payer and level of care, plus a review call with your leadership
Work inside the EHR you already run, under a signed BAA with 42 CFR Part 2 terms

Oregon billing questions

Payers, deadlines and how the service works.

Does every Oregon provider still get 110% of the OHP rate from CCOs?

No. Since January 1, 2026, CCOs must pay at least 110% of the OHP fee schedule only to Team-Based Care providers, who must attest with each CCO unless they qualify automatically. CareOregon's published policy pays outpatient mental health and SUD groups that do not qualify 90% of DMAP rates.

Do CCOs have to pay the OHP fee-for-service rates?

Not to contracted providers. CCOs set their own codes and rates through their contracts, subject to the 2026 directed payment floor for Team-Based Care providers. They must pay fee-for-service rates to non-contracted providers under OAR 410-120-1295.

How fast must Oregon commercial insurers pay a clean claim?

ORS 743B.450 requires an insurer to pay or deny a clean claim, or ask for more information, within 30 days of receipt. Unpaid claims earn 12 percent simple annual interest from day 31 under ORS 743B.452. Self-funded ERISA plans are generally not subject to these state laws.

Can PacificSource commercial plans pay for care by board-registered associates?

Not since October 1, 2026. Board-registered associates can no longer treat or bill behavioral health for PacificSource commercial and Medicare members, though Medicaid is unaffected. Group practices that staff associates on those caseloads need to move the patients to licensed clinicians or expect denials.

Is CCO credentialing included in your billing rate?

No. Credentialing and payer enrollment are handled by our consulting division and quoted separately. Each CCO credentials providers on its own, and claims from providers who are not credentialed may be denied as non-participating.

Guides for Oregon programs

Our Journal articles on the payers and rules above.

Request your free billing audit

Send 90 days of claims data for a free written review of your denials, aging AR and missed authorizations, with dollar amounts attached, across commercial, Medicare and OHP claims. A BAA is signed before any data changes hands, findings arrive within 5 business days of complete data, and you keep them whether or not you hire us.

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