2022 December Issue Network News

• Certification penalties
• Claim denials for medical records
• Credit balance resolution
• Dental maximum benefit
• HealthChoice direct data entry of claims and requests for additional information
• Overpayment notification
• New HealthChoice ID card for medical, dental and pharmacy
• HealthChoice is partnering with CARE
• HealthChoice EDI payer IDs and new group numbers
• Department of Corrections billing update
• HealthChoice Electronic Funds Transfer
• HealthChoice claim remittance vendor change
• Secure messaging through provider portal
• Timely filing and appeal deadlines for medical and dental claims
• New HealthChoice P.O. box addresses
• Certification portal update
• Contact information

When certification is not initiated and approved within the time frames described below, a 10% penalty is applied, if approved retrospectively. The member is not responsible for this penalty.

Certification is required within three business days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures. Certification is required within one day following emergency/urgent services.

Additional information about certifications is on the HealthChoice Provider site.

For questions about certification, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR.

What changes could you experience with claims denied for medical records beginning Jan. 1, 2023?

• By referencing the ineligible code, you will see the claim was denied for medical records on your HealthChoice remittance advice.
• You will also be notified with a letter telling you why the claim was denied and what records are needed to complete the review of the claim. This letter will include details on what is needed and where and how to submit the records back to UMR.
• When submitting records online, you will use the PCH tool. For questions on or issues with submitting medical records using the PCH tool, use the Contact Us option on the PCH website.

For questions about the medical records submission process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Beginning Jan. 1, 2023, HealthChoice will use Credit Balance from Optum to provide on-site and remote-location resources to help providers research and resolve unsolicited and solicited overpaid claims. 

What is credit balance resolution?

• This program audits credit balances and overpayments found and documented on provider ledgers.
• Optum verifies the members’ claims administered by UMR and notifies the provider of refund requests.
• Optum verifies the credit balance or overpayment amount and completes the recovery.
• Credit balance and overpayment recoveries made by Optum are sent to UMR monthly for crediting in the UMR claim payment system, and payment reimbursement is sent to HealthChoice.

For questions about credit balance resolution, call Optum at 615-503-1000, option 5.

The calendar year maximum benefit per person for network and non-network preventive, basic and major services combined is $2,500.

The member is responsible for all non-covered services and amounts above the calendar year maximum benefit. The HealthChoice discount applies to the service line where the maximum is met; all other service lines are denied in full as member responsibility.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR.

Providers can continue to access the Availity web portal for direct data entry of all claims in 2022 and prior dates of service. Providers are urged to submit claims for adjudication as soon as possible once services are rendered. This will ensure that claims may be timely adjudicated by HealthSCOPE during the designated run-out period.

What changes could you experience for data entry of claims and additional information, beginning Jan. 1, 2023?

The HealthChoice direct data entry of claims vendor will change to the UMR submissions vendor PCH for claims with dates of service on or after Jan. 1, 2023.

Steps to register

To register, visit the PCH home page:

1. Select My Account from the top menu bar.
2. Choose Sign up from the drop-down menu.
3. Complete the form (left) and select Submit.

What type of correspondence can be submitted through the PCH provider portal?

• Single-submission claims.
• Supporting dental documentation.
• Itemized medical statements and records.
• This application does not include submission for certifications.

Where can I go to check the status of submitted documents?

Providers can check the status of submitted documents in the Reports tab once you have access and log into PCH.

For questions about the direct data entry process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Examples of the overpayment notification and the corresponding remit advice notification and recoupment can be found here.

HealthChoice will be mailing new ID cards to all HealthChoice members in December for the 2023 plan year.

The new HealthChoice ID cards will now serve as the only insurance card for health, dental and pharmacy.

The new cards will also include the updated group number 76415077.

Medical, dental and RX plan sample card

HealthChoice is partnering with CARE to help give eligible plan participants the resources they need to live their best lives. Read more.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR. Providers will not need to make any changes to electronic data interchange (EDI) payer IDs in their system.

The payer ID or EDI number is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility, benefits and submit claims.

Continue to use the same HealthChoice, DOC and DRS EDI payer IDs used today after Jan. 1, 2023:

• 71064 HealthChoice.
• 71065 DOC and DRS.

Optum – UMR’s clearinghouse for claim files – works with several clearinghouses to receive claims.

HealthChoice members will receive new ID cards for the 2023 plan year that will reflect the payer IDs listed above. The new ID cards will also have these UMR-assigned group numbers:

• 76415077 HealthChoice (member IDs will remain the same).
• 76415170 Oklahoma DOC (member IDs will continue to be the inmate ID).
• 76415171 Oklahoma DRS (UMR will issue new member IDs).

For questions regarding this update, call Customer Care at 800-323-4314. TTY users call 711.

The Department of Corrections (DOC) is transitioning from its current third-party administrator, HealthSCOPE benefits, to UMR effective Jan. 1, 2023.

For dates of service on or after Jan. 1, 2023, DOC providers will need to:

• Bill with group number 76415170.
• Update the member ID to utilize a prefix of 3650 + the DOC inmate ID number.
• Enter the prefix 3650 + DOC inmate ID number when making a DOC inquiry using the IVR system or UMR Portal.

For questions, call the Customer Care team at toll-free 800-323-3710.

UMR will be the new claims processor for HealthChoice, DOC and DRS processing claims with dates of service beginning Jan. 1, 2023. As a provider, you will be able to receive direct deposit of claim payments processed by UMR.

HealthChoice encourages you to enroll now with Optum Pay or by calling 877-620-6194. 

You will need the following information to complete your enrollment online: 

• The payment method for your organization. 
  • Direct deposit (ACH).
  • Virtual card payments (VCP).
• Organization name, mailing information and tax identification number (TIN).
• Contact information for your designated Optum Pay contacts.
• Banking information for the ACH option.
• Your organization's W-9 form.
• A voided check or bank letter for each account where payments will be deposited for the ACH option.
• There will be an option to enroll for virtual card payments. 
  • This option is currently not available for payments made by HealthChoice.
  • If you enroll for virtual cards in error, you will receive checks.
  • Virtual cards will be available as a payment option in 2023.

What happens if I do not enroll? 

• You will receive a paper check for dates of service after Jan. 1, 2023, if you are not enrolled in Optum Pay.

Benefits of electronic payments

• Payments arrive sooner than checks.
• No lost payments.
• Often see less administrative costs with receiving electronic payments.
• Payments viewable through the Optum Pay web portal. 
  • Free basic service or paid premium service available with more robust reporting options.
  • Remittance advices and 835 transaction data is available.

For questions about EFT enrollment, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

UMR will be the new claims processor for HealthChoice, DOC and DRS claims with dates of service beginning Jan. 1, 2023. The payment disbursement vendor will also change from ECHO Health to Optum. HealthSCOPE Benefits will continue to process claims received in 2023 with a 2022 date of service, and ECHO Health will continue to process those payments.

Providers

If you are currently enrolled under UMR payer ID 39026 with OptumInsight for 835 electronic remittance advices or Optum Pay for ERAs, you do not need to register.

If you are not currently enrolled for remittances under UMR payer ID 39026, you can enroll at any time. UMR will automatically transfer your enrollment from payer ID 39026 to HealthChoice payer ID 71064 and DOC\DRS payer ID 71065 effective Jan. 1, 2023.

To enroll for ERAs via OptumInsight, call 866-367-9778 and choose Option 1.

• If you contact OptumInsight prior to Jan. 1, 2023, ask to enroll for payer ID 39026.
• If you contact OptumInsight after Jan. 1, 2023, ask to enroll for payer IDs 71064 and 71065.

You can also enroll for Optum Pay ERAs. With this option, you can view and download remittance information. HealthChoice encourages you to enroll or confirm you are currently enrolled by calling 877-620-6194.

Clearinghouse connections

You can also enroll to receive ERAs through your current clearinghouse. Clearinghouses can enroll you using the Optum portal.

• If you request to enroll prior to Jan. 1, 2023, ask your clearinghouse to enroll you for payer ID 39026.
• If you request to enroll after Jan. 1, 2023, ask your clearinghouse to enroll you for payer IDs 71064 and 71065.

What happens if I do not enroll for ERAs by Jan. 1, 2023?

If you do not enroll for 835 remittances or ERAs, you will need to view claim information on the HealthChoice provider portal or request copies of remittances from Customer Care at 800-323-4314.

If you have any questions, please call Customer Care at 800-323-4314.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR. For portal claim communications, UMR uses Optum Secure Messaging.

What changes will you experience for sending and receiving secure messages starting Jan. 1?

On the HealthChoice provider portal under Contact us, you will see a new feature that allows you to send and receive messages for claims with dates of service on or after Jan. 1, 2023.

Once signed into the website, select the Contact us icon at the top of the screen to initiate a conversation.

By selecting the Messages icon, you will be able to view sent and receive messages.

All HealthChoice contracts contain timely filing provisions.

The following updates have been made to deadlines for claims filing:

For additional information, please call EGID Network Management at 405-717-8790 or toll-free
844-804-2642. TTY users call 711.

Jan. 2, 2023, HealthChoice will have NEW post office box addresses for all claims, claim correspondence and claim appeals.

UMR is replacing HealthSCOPE Benefits as the third-party administrator for HealthChoice, DRS and DOC Jan. 1, 2023. UMR will take over services related to the receipt and processing of all claims, claim correspondence and claim appeals. The change in TPAs requires a change to the HealthChoice mailing addresses below:

For HealthChoice claims with dates of service prior to Jan. 1, 2023, the current addresses will be available for six months after Dec. 31, 2022, to accommodate the timely filing of claims. 

For questions about the claim submission process, call Customer Care at 800-323-4314. TTY users call 711.

All certification requests initiated after Dec. 30, 2022, must be submitted through the HealthChoice provider portal, regardless of the date of service. Initiate a request from the UMR certification portal at HealthChoiceOK.com. To navigate to the portal, select Providers from the menu and then select the portal. From the portal log-in page and within the portal, you will select Get certification, as shown below.

The HealthChoice certification vendor, American Health Holdings (AHH), will be replaced by the UMR CARE Team. The HealthCare Management Unit (HCMU) will continue to review some certification requests as they do today.

AHH will notify UMR of any certifications that carry over into 2023 and will be available in the UMR system.

For questions about the certification process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.