Oregon Medicaid Enrollment –
For In and Out of Network Providers

Enrollment

Has a claim already been submitted? (If no, please do not delay submitting it as it may affect the 120 day timely filing requirement.)

If you have submitted your claim(s) and received a denial, your claim should auto-reprocess once your DMAP number has been posted to the State’s weekly DMAP Provider file.

Enroll a Facility

Please complete the following forms along with supporting documents and the contact information above.

For a billing provider, facility, organization:

1. Completed and signed copy of OHA 3975 form
2. Copy of current individual license.
3. Completed and signed copy of OHA 3974 form
4. Current, signed W9
5. Copy of current facility/organization license

Enroll a Provider

A separate form will need to be completed for each rendering provider. If the facility already has an active Oregon DMAP number, then only the rendering provider needs enrolled.

For an individual rendering provider:

1. Completed and signed copy of OHA 3975 form

Submitting Documentation

Provider Enrollment requests can be sent to Ayin via:

• Fax to 503-315-4138, this will create a ticket, but please include an email address and other contact information to enable correspondence.
• Email to map.enrollment@phtech.com, you will receive an email confirmation containing the ticket number as well as a link to the ticket.
• Enrollment requests could also be submitted via Ayin’s Help Center Portal, Zendesk. This method helps the submitter to provide all of the needed information and cuts down on the need for Ayin to request additional information.

See the Step-by-Step Guide to submitting provider enrollment requests.