2022 November Issue Network News

Certification penalties
HealthChoice advanced claim review implementation
Update to dental code D0350
HealthChoice code review vendor change
New HealthChoice ID card for medical, dental and pharmacy
Department of Corrections billing update 
VARIS update
Copays for primary care and specialists
HealthChoice Electronic Funds Transfer 
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.

HealthChoice is adding an advanced claim review (ACR). This program selects certain claims for additional coding review.

Reviews are performed by experts, including some specialty board certified physicians, registered nurses and certified coders. Medical records and/or itemized bills will be required for review.

If claims with billing and/or coding errors are identified, they will be processed to reflect the appropriate payment. Claims are reviewed pre-payment or post-payment.

What changes could you experience for claim editing starting Jan.1, 2023?

1. Certain claims may deny for medical records if not already received from the provider or facility.
2. If error(s) are identified, claims may partially or fully deny as:

a. Code billed is a component of another code (unbundling).
b. Over unit maximum.
c. Code billed not documented in medical records.
d. Billed DRG not supported in medical records.

For HealthChoice claims with dates of service prior to Jan. 1, 2023, ACR will not apply.

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

Beginning Jan. 1, 2023, HealthChoice will allow a maximum reimbursement of one unit per 12 calendar months for dental code D0350, which covers an unlimited number of photos. D0350 will not be reimbursed per tooth or per quadrant. Services billed that exceed the limitation will be applied to member responsibility.

Refer to the HealthChoice Fee Schedule(s) for coverage of codes, allowable fees and certification requirements.

For questions about eligibility and benefits, certifications or exclusions pertaining to medical or dental care, refer to the dental plan handbook or 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.

The HealthChoice code review vendor will also change from HealthSCOPE/McKesson to UMR/Clinical Editing System (CES).

The UMR Code Review team reviews all newly implemented codes. CES applies the editing on claims received for processing.

What changes might you experience for claim editing, beginning Jan. 1, 2023?

1. Claims with a code-to-code relationship present, billing of modifier 59 or equivalent X modifiers will not automatically override the claim editing. UMR will require medical records for review.
2. Claims with a code-to-code relationship present between an E & M code and procedure code, billing of a modifier 25 will not automatically override the claim editing. UMR will require medical records for review.
3. HealthChoice facility claims will now receive code editing.

For HealthChoice claims with dates of service before Jan. 1, 2023, HealthSCOPE/McKesson will continue to apply editing on claims.

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

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

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 76415171.
• 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.

As we transition to UMR on Jan. 1, 2023, we will be moving from VARIS for inpatient post-payment review to UMR.

Providing medical records to VARIS timely will be critical during this change. All medical records will need to be sent directly to the address indicated on the request. There could be a possible retraction of the full payment if the records are not received on time.

VARIS will review the medical records and provide a letter with rationale for any potential change to the DRG. The facility will have 60 days to sign the acknowledgement letter and include the overpayment. If you do not agree with the DRG change, please send a letter of appeal and any additional supporting documentation to VARIS. All contract provisions apply.

VARIS will work directly with you regarding any questions from your facility.

For dates of services after Jan. 1, 2023, HealthChoice is changing the psychiatric office visit copay from a specialist copay of $50 to a primary care office visit copay of $30.

The following specialties are subject to the primary care office visit copay of $30.

• General practice.
• Internal medicine.
• Obstetrics/gynecology.
• Pediatric medicine.
• Physician assistant.
• Nurse practitioner.
• Psychiatry.
• Geriatrics.
• Preventive medicine.
• Urgent care.
• Rural health clinics.
• Federally qualified health centers.
• Military facilities.
• VA facilities.
• Indian health facilities.

All other specialties are subject to the specialist office visit copay which remains $50.

For questions about eligibility and benefits, 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 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.

Beginning Jan. 1, 2023, certification processing for HealthChoice will transition to UMR.

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.

What changes could you experience for certifications beginning Jan. 1, 2023?

1. Access the certification portal by logging on at HealthChoiceOK.com. Once logged on, you can submit a certification request for 2023 dates of service, view the status of a 2023 certification or request an appeal.
2. If you are logging on for the first time, you will need to create a login with a new username and password.
3. All certification requests will be initiated through UMR CARE and will be reviewed by the UMR CARE team or HCMU according to the EGID certification requirements.
4. Paper forms and faxes will no longer be accepted when initiating certification.
   a. To initiate a new certification, select Get Certification.
   b. You will then be guided through the required information to submit a certification request.

The new certification portal will be available through HealthChoiceOK.com after close of business on Dec. 30, 2022.

For certification requests initiated prior to close of business on Dec. 30, 2022 providers may continue to utilize the HealthChoice online certification portal on HealthChoice Connect, regardless of the date of service. 

Any certification requests initiated on or after Dec. 31, 2022, must be made through the UMR certification portal at HealthChoiceOK.com regardless of the date of service.

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