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
Aug 19, 2026
Summary
Effective July 1, 2020, Oregon Health Plan (OHP) pharmacies can no longer use Other Coverage Code (OCC) 1 to override claim denials for patients with third-party liability. 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 must contact software vendor or corporate helpdesk to ensure OCC 1 is not prepopulated in patient profiles for OHP fee-for-service prescriptions. (2) Before submitting any claim for OHP patients with other coverage, report the patient's primary payer to OHA via www.ReportTPL.org. (3) Bill the primary payer first, then bill OHP using the correct OCC code (2, 3, or 4) based on primary payer's action: use OCC 2 if primary paid in part/full; OCC 3 if primary denied with valid NCPDP reject code; OCC 4 if primary approved but no payment occurred. (4) Ensure prescribers initiate prior authorizations with primary payer if required. (5) Remove any automated OCC 1 overrides from billing workflows and encounter forms. Failure to comply will result in claim denials for all OHP prescriptions claiming other coverage starting July 1, 2020. Contact Oregon Pharmacy Call Center at 1-888-202-2126 with questions.