MedicaidAdministrativeHigh impact
Other Coverage Code (OCC) 1 override ends July 1, 2020
Oregon Health Plan·OR · Pharmacy·Provider
Effective date
Jul 1, 2020
We identified it
Jun 20, 2026
Summary
Oregon Health Plan (OHP) pharmacies can no longer use Other Coverage Code (OCC) 1 to override claim denials for patients with third-party liability starting July 1, 2020. Claims using OCC 1 will be denied. Pharmacies must instead use OCC codes 2, 3, or 4 based on how the primary payer processed the claim, and must report the patient's primary payer to OHA prior to billing.
Action Required
By June 30, 2020: (1) Billing team and software vendor must remove OCC 1 prepopulation from client profiles in billing system. (2) Pharmacy staff must report all patients with third-party liability (TPL) to OHA via www.ReportTPL.org prior to billing prescriptions. (3) Update billing workflow to require staff to select appropriate OCC code (2, 3, or 4) based on primary payer's response: OCC 2 for claims paid by primary payer, OCC 3 for claims denied by primary payer (with required NCPDP reject code), or OCC 4 for approved claims with no payment. (4) Pharmacy staff must bill TPL as primary payer first before billing OHA. (5) Instruct prescribers to obtain prior authorization from primary payer if required. Failure to comply will result in claim denials to OHA. Contact Oregon Pharmacy Call Center at 1-888-202-2126 with questions.