2023 Winter Network News

• Department of Corrections billing update
• Faxed certification requests are no longer accepted
• Electronic Funds Transfer
• Dental pre-determinations
• Dental maximum benefit
• Certification penalties
• Outpatient Reimbursement Methodology
• Copays for primary care and specialists
• Enhanced portal features for HealthChoice
• Fee schedule updates
• HealthChoice contact information

The Department of Corrections (DOC) transitioned from HealthSCOPE benefits as its third-party administrator to UMR.

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

• Bill with group number 76415170.
• Update the inmate 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 provider portal.

For questions, call the Customer Care team at toll-free 800-323-3710. TTY users call 711.

As previously communicated in the Network News, as of Jan. 1, 2023, HealthChoice no longer accepts faxed certification requests. All certification requests must be entered through the provider portal.

At the end of January 2023, the existing certification fax numbers for HCMU will be decommissioned. Through the portal, responses and updates to your certification requests are quicker, and certification requests are more efficient than filling out the forms previously used.

If you have questions or need assistance with the portal, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

As a provider, you can receive direct deposits of claim payments processed by the claims administrator, UMR.

HealthChoice encourages you to enroll online with Optum Pay, a multi-payer platform, or enroll by calling 877-620-6194 to ensure the payment delivery of your choice.

To complete online enrollment, you need:

• Organization name, mailing address and tax identification number (TIN).
• Your contact information.
• 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 later this year.

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

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.

Dental providers should not use a date of service when submitting pre-determinations, per ADA guidelines.

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

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.

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.

In 2019, HealthChoice adopted the CMS outpatient consolidated payment methodology for urban outpatient reimbursement. This applies to claims containing an HCPCS code with a status indicator of J1.

Under the CMS Hospital Outpatient Prospective Payment System (OPPS), comprehensive APC (C-APC) HCPCS codes are designated with a J1 status indicator on the OPPS Addendum B. The single payment for a C-APC is based on the primary HCPCS code with a J1 indicator and generally includes all services and items billed on the outpatient claim. There are a few carve-out items that receive separate reimbursement.

Additional rules apply to C-APC consolidated payments under CMS.

For more information, reference the current CMS OPPS files or email EGID Network Management or call 405-717-8790, toll-free 844-804-2642. TTY users call 711.

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.

With the third-party administrator transition to UMR on Jan. 1, 2023, you will see many improvements.

Employees Group Insurance Division will continue to administer HealthChoice, determining plan benefits, administrative rules and reimbursement. UMR adds enhanced integrated provider support with flexible technology and advances in automated procedures.

You will experience user-friendly access to benefits, eligibility, claim status, remittance advice, certification requests, filing appeals, and payment options, as well as ease of submitting requested documentation with the new provider portal.

Access to the provider portals is available at HealthChoiceOK.com. For benefits, eligibility and services on or after Jan. 1, 2023, use the new portal. The first time you use it, you will need to create or use an existing One Healthcare ID, and then create a new provider account even if you have used the previous portal. For claim status and remittance advice for services prior to 2023, continue to use the HealthChoice Connect portal.