Important Change! Effective December 1st, 2020, EOCCO will require all providers to complete the Provider Enrollment Agreement 3975 (PEA). This form has been added to the application found below. Please note that the application will not be processed by OHA if the PEA is incomplete.
On March 25, 2011, DMAP began requiring all healthcare providers and suppliers to submit both Social Security numbers and date of birth information when they are initially enrolling or revalidating their enrollment with DHS/OHA. This requirement applies to providers contracting with managed care plans or as a non-participating managed care plan provider.
DMAP is taking this action as required under Section 6401 of the Patient Protection and Affordable Care Act (PPACA), signed into law on March 23, 2010. The CMS final rule addressing Section 6401 of the PPACA is CMS-6028-FC. This can be found online at edocket.access.gpo.gov/2011/2011-1686.htm.
This requirement applies equally to each provider or supplier, each person with ownership or control interest in the provider or supplier, any subcontractor that the provider or supplier directly or indirectly has a five percent (5%) or more ownership interest, and any managing employees including directors and officers of corporations, non-profit organizations and charities.
If you are not registered with DMAP, please complete the managed care plan rendering provider application and the managed care plan facility clinic application, below. You may send these forms via fax 503-265-4790 or by email to ProviderDMAPApps@modahealth.com.
EOCCO will deny claims from providers who are not registered with DMAP.
I want to join the panel and initiate a contract as a new provider:
I am an existing provider and I want to renew my contract:
I need a copy of my current contract:
Updating demographic information:
Billing policy information:
Before you submit an application with Oregon Medicaid, please ensure that you have your certification and registration through OHA Office of Equity and Inclusion and an active National Provider Identification (NPI).
For more information please see the Community Health Workers DMAP Enrollment and Reimbursement instructions.
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