2025 Spring Network News

• Provider customer service
• HealthChoice contracts and applications
• Place of service code 03
• Place of service code 02 on professional claims
• Submitting medical records with claims
• Executive Order 2025-16
• Newborn DRG reimbursement
• New coding edit for procedures requiring an anatomical modifier.
• Update to modifiers that impact pricing policy
• Fee schedule updates
• HealthChoice contact information

Customer Care is available to help with issues involving eligibility, benefits, claims, coverage, certification and appeals. Portions of this information can be viewed on the HealthChoice Provider Portal, or you can contact Customer Care at toll-free 800-323-4314. TTY users 711.

EGID Network Management is available for assistance for providers participating in the HealthChoice, DOC and DRS networks. Contact EGID Network Management with any questions pertaining to contracting, updating network provider demographics, provider directory updates, fee schedules and fee schedule access.

Demographic information can be viewed and updated on the Provider Contracting Self-service Portal. Additional information can be found in the Policies and Guidelines section of the provider website.

If you have further questions or concerns or are unable to get a resolution after speaking with Customer Care, please request a call reference number and contact EGID Network Management.

Office hours for EGID Network Management are 8 a.m-4:30 p.m., Monday through Friday, excluding state holidays. For any inquiries, email EGID Network Management, or call 405-717-8780 or toll-free 800-752-9475. TTY users 711.

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HealthChoice only accepts the most current version of the contract and application and forms, located on the HealthChoice Providers webpage.

Complete and return the most appropriate contract and application, along with the required attachments, when adding a new TIN to EGID Network Management. HealthChoice accepts digital and e-signatures on all documents.

For questions or further information, email EGID Network Management or call 405-717-8780 or toll-free 800-752-9475. TTY users call 711.

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According to the HealthChoice Health Plans Handbook, any services provided in a school or daycare, POS 03, are excluded from coverage.

HealthChoice does not allow services, treatments, items or supplies, except as specifically provided for under Covered Services, Supplies and Equipment listed in the handbook. Plan exclusions are not covered even if prescribed or the only available treatment for a condition. Some services may be medically necessary but not covered by the plan.

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

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Effective Jan. 1, 2026, professional claims coded with POS 02 will be reimbursed using the facility rate on the professional fee schedule. Additional information can be obtained by logging in to the HealthChoice fee schedule portal or reviewing the provider Policies and Guidelines.

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

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You can now submit medical records with your electronic claims through clearinghouses that support a standard 275 submission and have an established connection with OptumInsight.

When uploading clinical documentation to the provider portal, all submitted medical records must include the patient’s name and date of birth to comply with HIPAA requirements.

Submitting medical records at the time of claim submission reduces the likelihood of claim denials for additional information and increase the potential autopayment rate.

Electronically submitted claims with medical records will pend for review and no longer deny requesting for medical records.

OptumInsight continues to work to include additional clearinghouses. Please check with your clearinghouse to see if they have a connection through OptumInsight.

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

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As a state agency, EGID is required to comply with Executive Order 2025-16, which restricts state agencies from providing state funds to any individual or facility affiliated with a physician, medical practice or other organization providing abortion services or facilitating the procurement of abortion services.

In accordance with this directive, we are adding the following language to our Network provider contracts:

“Pursuant to Executive Order 2025-16, the provider certifies that it is not and will not be, during the term of this contract, affiliated with a physician, medical practice or other organization providing abortion services or facilitating the procurement of abortion services.”

By remaining contracted with HealthChoice, the Department of Rehabilitation Services or the Department of Corrections, all Network providers agree to these terms.

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Effective Oct. 1, 2025, HealthChoice will transition to an allowable for the inpatient newborn MS-DRG codes listed below. Currently, we allow 70% of billed charges. Rates will be published with the new MS-DRG fee schedule near Oct. 1, 2025.

For questions, email EGID Network Management or call us at 405-717-8780 or toll-free 800-752-9475.

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This policy addresses the appropriate use of modifiers with certain CPT and HCPCS procedure codes. According to the Centers for Medicare and Medicaid Services (CMS), a modifier is a two- character code added, when appropriate, to the end of a procedure or service to clarify the services being billed. Modifiers add more information to the code, such as the anatomical site. In addition, they help eliminate the appearance of duplicate billing and unbundling. Modifiers are used to increase accuracy in reimbursement, coding consistency, editing, and capturing payment data.

Anatomical modifiers are used to designate the specific area of the body where a procedure was performed. Use of laterality and anatomical modifiers help to provide the highest specificity for the procedure being performed. In alignment with American Medical Association (AMA), CPT and CMS, effective Jan. 1, 2026, HealthChoice requires surgical procedure codes, specifically range 10000- 69999, assigned a bilateral indicator of “1” on the National Physician Fee Schedule be billed with the appropriate anatomical modifier.

Laterality and anatomical modifiers include:

Claims received that do not include the appropriate modifier will be denied and a corrected claim required.

For questions, call Customer Care at toll-free 800-323-4314.

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As a reminder, certain modifiers can impact pricing. Services that use modifiers and are considered incidental, mutually exclusive, integral to the primary service being rendered or part of a global allowance are not eligible for separate reimbursement.

The following table lists the additional modifiers that have recently been added to the list of modifiers that impact pricing, along with their HealthChoice reductions to the allowable fee listed in the Policies and Guidelines section of the provider site. The list may not be all-inclusive. Other modifiers may impact the allowable fee.

These reductions are subject to change with notification via the HealthChoice Provider Network News.

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Future fee schedule updates for services by HealthChoice network providers are scheduled for:

*Comp =Comprehensive; A/C/D = Adds, changes, deletes and other necessary updates.

As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. When that occurs, EGID reviews the modifications as quickly as possible and makes any necessary updates. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary.

The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban or rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area.

Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1. These designations are determined by the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the facility's ZIP code, included in the U.S. Census Bureau's metropolitan core-based statistical area. On Jan. 1, the urban/rural indicators are updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals.

For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area.

Inpatient and outpatient tier designations are defined as:

• Tier 1 – Network urban facilities with greater than 300 beds.
• Tier 2 – All other urban and non-network facilities.
• Tier 3 – Critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
• Tier 4 – All other network rural facilities.
• Tier 6 – Outpatient rural emergency hospitals.

Fee schedule updates are reported in each quarterly issue of the Network News. If you need specific codes and allowable fees affected by these updates, please view or download the latest fee schedule. The fee schedule has not been publicly disclosed and is deemed confidential pursuant to 51 O.S. and should not be disseminated, distributed or copied to persons not authorized to receive the information.

For more information, email EGID Network Management or call 405-717-8780 or toll-free 800-752-9475. TTY users call 711.

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