2023 Behavioral Health Provider Qualified Directed Payment (QDP)

In 2022, the Oregon Health Authority (OHA) sought and received additional funds via House Bill 5202. The OHA submitted requests for authorization, to the Centers for Medicare and Medicaid Services (CMS), to implement changes in the Oregon Health Plan (OHP) Fee-for-Service Fee Schedule and to implement a new Qualified Directed Payment structure. These two approaches support increased payments for both Open Card Fee-For-Service payments and CCO payments. The two different structures are:

• OHP Fee-for-Service Fee Schedule (often referred to as DMAP rates): Changes to the OHP Fee-for Service Fee Schedule is the vehicle being used to increase rates for services provided to Open Card members (OHP members who have not been assigned to a CCO).

• Qualified Directed Payments (QDP): To increase continuity of payment levels across CCOs, the OHA has added QDP requirements to each CCO’s contract. This new language outlines four (4) different “tiers” for payment. Effective January 1, 2023, through December 31, 2023, the approved payment mechanism is called a “Directed Payment.” Approval of this payment mechanism is authorized through CMS regulation (42 CFR 438.6). 

Overview of Tiered Qualified Directed Payments

Tier 1: Increases payment for treatment services delivered by qualifying provider types. This Tier applies to Providers who meet one or more of the following service categories:

• Assertive Community Treatment (ACT)

• Supported Employment Services (SE)

• Outpatient Mental Health Treatment and Services (OPMH)

• Outpatient Substance Use Disorder Treatment and Services (OP SUD)

Payment rates will be calculated based on whether the Behavioral Health (BH) Qualifying Provider derives its Behavioral Health revenue primarily from providing services to individuals enrolled in Oregon’s Medicaid and Children’s Health Insurance Program (CHIP) programs. A BH Participating Provider is regarded as “Primarily Medicaid” if at least fifty percent (50%) of their revenue came from providing Medicaid services in the prior Contract Year.

All qualified Providers will default to the Medicaid Non-Dominant rate (15%) increase unless the Provider submits a complete qualifying Attestation Form.

If you believe that you qualify for Tier 1 “Primarily Medicaid” level of payment (30%) complete the Primarily Medicaid Provider Attestation Form which is here: 

2024 Provider Medicaid-Focused Attestation Form 

• 2024 Behavioral Health Direct Payment Guidance Document
• Behavioral Health Direct Payment FAQs

Upon completion of the Primarily Medicaid Provider Attestation Form, please submit the document to YCCO Provider Relations at providerrelations@yamhillcco.org

Tier 2: The Integrated Co-Occurring Disorder (ICOD) Services payment increase is applicable for BH Participating Providers approved by OHA for provision of integrated treatment of Co-Occurring Disorders (ICOD) pursuant to OAR 309-019-0145. Programs will need to have previous and current Behavioral Health Certification of Approval and meet requirements that OHA will add to Oregon Administrative Rule 309-019-0145.

Payment increase(s) vary by category:

• 10% of the State Plan Medicaid Behavioral Health Fee-For-Service fee schedule rate effective Jan. 1, 2023, for covered non-residential services provided by providers below a master’s level, including peer service providers.
• 20% of the Medicaid fee schedule rate in effect on Jan. 1, 2023, for covered non-residential services for master’s level providers.
• 15% of the Medicaid fee schedule rate in effect on Jan. 1, 2023, for residential services providers.  

To receive increased payments, qualifying providers must follow OHA established directions for submission of claims. This includes the requirement that a COD diagnostic combination must be present on each qualified encounter. *OHA will provide detailed diagnosis code lists in a separate COD implementation guide.

Additionally, OHA approved ICOD Providers will be required to add applicable modifiers to claims filed in order to receive the increased rate for qualifying services.

For non-residential ICOD Providers:

• Master’s level provider: use modifier HO for eligible services to receive the additional 20%.
• All other providers: use modified HH for eligible services to receive the additional 10%. 

For qualified residential ICOD Providers/Services:

·       H0010, H0011, and H0018: Use modifier HH (Other conditions: Must be a licensed SUD Program)

·       H0019: Use modifier HH (Other conditions: None)

·       H2013: Use modifier Not HK (Other conditions: None)

If you believe that you qualify for Tier 2 Integrated Co-Occurring Disorder (ICOD) Services payment complete the OHA approval process which can be found at: www.oregon.gov/icd

Tier 3: Increase for OHA Authorized Providers who are approved by OHA as a Provider of Culturally and Linguistically Specific Services (CLSS). The percent that a payment is increased for a qualifying service is based on whether the Provider is delivering services in a rural or non-rural area.

Eligible providers will fall into one of five categories:

1. CLSS Organization, an organization which delivers CLSS BH services to its clients.
2. CLSS Program, a program which exists within a larger organization and that delivers CLSS BH services to its clients.
3.  CLSS Individual Provider, an individual who delivers CLSS services to their clients.
4.   Individual Bilingual Provider, an individual provider who delivers direct care BH services in a language other than English.  (Not Interpretation)
5.   Individual Sign Language Provider, an individual provider who delivers direct care BH services in sign language. (Not Interpretation)

OHA approved CLSS Providers will be required to add applicable modifiers to claims filed in order to receive the increased rate for qualifying services.

·       CLSS Rural provider modifier: TN

·       CLSS non-rural provider modifier: U9

If you believe that you qualify for Tier 3 Culturally and Linguistically Specific Services (CLSS) payment complete the OHA CLSS Behavioral Health Provider application process which can be found at: https://www.oregon.gov/OHA/HSD/OHP/Pages/BH-Rate-Increase.aspx

Tier 4: Assurance that applicable providers are paid no less than Behavioral Health Oregon Medicaid fee-for-service (FFS).

No additional action is needed by Providers.

For additional information and resources, please see:

       Qualified Directed Payment Overview

        OHA Provider Webinars https://www.oregon.gov/oha/HSD/OHP/Pages/BH-Rate-Increase.aspx

     2023 Medicaid Behavioral Health Provider Directed Payment Increase Information

Questions about this program or your eligibility, please contact Yamhill Community Care ProviderRelations@yamhillcco.org

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New PCP Assignment Policy active January 1st, 2021

View PCP Assignment and Engagement FAQ

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Provider information is available 24/7 through
the Provider Portal (CIM)

The Portal makes it convenient to access patient eligibility, review claims/payment information, submit a claim, check on the status of a referral, or submit one and has information regarding prior authorizations.

Please note: all prior authorizations are to be submitted through the portal. 

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If you are a new provider who needs access to the portal, or if you are an established provider with portal questions, please submit an online request below or call Customer Service at 855-722-8205.

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Submitting a claim is easy

Submit electronically using the provider portal or by logging in directly to CIM. If you need assistance on submitting a claim submit call Customer Service at 855-722-8205.

Claims can also be mailed to:

Yamhill Community Care
PO Box 5490
Salem, OR 97304

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To receive electronic claims payments and/or remittances please register with Payspan. You will need a Registration Code and PIN in order to register. Please contact PaySpan Provider Services at 877-331-7154, Option 1 for assistance.