MedicaidAdministrativeHigh impact
OCC 1 override for fee-for-service prescriptions ends September 2, 2019
Oregon Health Plan·OR · Pharmacy·Provider
Effective date
Sep 3, 2019
We identified it
Jun 20, 2026
Summary
Oregon Health Plan (OHP) is ending the use of Other Coverage Code (OCC) 1 override for fee-for-service pharmacy prescriptions effective September 3, 2019. Pharmacies must stop using OCC 1 to override claim denials and instead use appropriate OCC codes 2, 3, or 4 based on primary payer processing. Claims submitted with OCC 1 after the effective date will be denied.
Action Required
By September 2, 2019: (1) Billing team must contact software vendor or corporate helpdesk to ensure OCC 1 is not prepopulated in patient profiles for OHP fee-for-service prescriptions. (2) Verify all patients with third-party liability (TPL) have their primary payer reported to OHA at www.ReportTPL.org before billing to OHP. (3) Update billing workflow to require staff to bill TPL as primary first and use only OCC codes 2, 3, or 4 when billing OHP secondary—specifically: use OCC 2 when primary payer pays in part or full, OCC 3 when primary payer denies with valid NCPDP reject code, or OCC 4 when primary payer approves but doesn't pay (deductible/copay phase). (4) Ensure prescribers initiate prior authorization with primary payers when required. Failure to comply will result in OHP claim denials for all fee-for-service prescriptions with OCC 1 after September 3, 2019. Contact Oregon Pharmacy Call Center at 1-888-202-2126 with questions.