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
Aug 19, 2026
Summary
Starting September 3, 2019, Oregon Health Plan (OHP) pharmacies can no longer use Other Coverage Code (OCC) 1 to override claim denials for fee-for-service prescriptions when patients have third-party liability (TPL). Claims using OCC 1 will now deny. Pharmacies must use OCC codes 2, 3, or 4 based on how the primary payer processed the claim, and must report TPL to OHA prior to billing.
Action Required
By September 2, 2019: (1) Billing team must contact software vendor or corporate helpdesk to ensure OCC 1 is not prepopulated in client profiles for OHP fee-for-service prescriptions. (2) Implement process to report all patients' primary payers to OHA via www.ReportTPL.org before billing to OHP. (3) Update billing workflow to require selection of appropriate OCC code (2, 3, or 4) based on primary payer response: use OCC 2 when primary payer paid in part or full, OCC 3 when primary payer denied with valid NCPDP reject code, or OCC 4 when primary payer approved but did not result in payment. (4) Ensure prescribers initiate prior authorizations with primary payers when required before submitting to OHP. Consequence: Claims submitted with OCC 1 on or after September 3, 2019 will be denied by OHA.