Provider updates

What is changing?

Effective May 1, 2026 CareOregon will be implementing updates to the way we pay certain outpatient diagnostic and admission-related nondiagnostic services provided prior to an inpatient hospital admission. These changes apply to Columbia Pacific CCO, Jackson Care Connect, Health Share of Oregon, and CareOregon Advantage.

Certain outpatient services will now be required to be included on the inpatient claim when provided shortly before the admission:

• Inpatient Prospective Payment System (IPPS) Hospitals: Outpatient diagnostic and admission related nondiagnostic services provided on the date of admission or within 3 days prior must be bundled into the inpatient claim.
• Non-IPPS Hospitals: A 1-day window applies.
• Critical Access Hospitals: Not subject to the 3-day/1-day payment window.
• Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs): Window does not apply to services covered under their all-inclusive rate.

These updates apply to both the admitting hospital, and any hospital-owned or hospital-run clinics, programs, or service sites.

Why are we making this change?

This change aims to improve consistency in how outpatient services are reimbursed when they occur shortly before an inpatient admission. We are making this change to ensure alignment with guidance from Centers for Medicaid and Medicare Services (CMS) regarding the Preadmission Payment Window (3Day/1Day Rule) SE20024 - FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients,

What is not changing?

Outpatient diagnostic services such as laboratory tests and imaging, along with admission related outpatient nondiagnostic services like therapeutic procedures that are clinically related to the inpatient stay, are not separately reimbursable when they are provided on the date of admission or during the three calendar days preceding the admission for IPPS hospitals, or within one day for non IPPS hospitals.

Certain services are excluded from the preadmission payment window and may be billed separately, including:

• Ambulance services
• Outpatient maintenance renal dialysis
• Services that are clinically unrelated to the inpatient admission (must be attested with Condition Code 51)
• Critical Access Hospitals (CAHs)
• Non‑subsection (d) hospitals or units excluded from the IPPS
• Emergency Department services provided on days prior to the admission date
• Crisis support services and other behavioral health services furnished prior to admission

We understand that these changes may require adjustments to your current billing practices. Our goal is to ensure that all services are billed accurately and in accordance with the payor group's guidelines. We appreciate your cooperation and understanding as we implement these changes. 

You can find additional information in the coding guide on our website.

• CareOregon: Provider coding quick guides
• Jackson Care Connect: Provider coding quick guides
• Columbia Pacific CCO: Provider support

If you have any questions or need further clarification, please do not hesitate to contact CareOregon Provider Relations. 

Provider Relations:

• CareOregon/Health Share: Metrobhprs@careoregon.org
• Jackson Care Connect: jacksonprs@careoregon.org
• Columbia Pacific CCO: colpacPRS@careoregon.org