2025 Spring Network News

• Claims submissions
• Reimbursement for applied behavioral analysis (ABA)
• Modifiers CO and CQ
• Medical records following claim denials
• Laboratory drug screenings
• Physical therapy bundles added to the Select program
• Reimagined provider portal
• Update on electronic claims transmissions
• E&M codes billed with manipulation treatment
• Fee schedule updates
• HealthChoice contact information

HealthChoice, the Department of Corrections (DOC) and the Department of Rehabilitation Services (DRS) offer a variety of options for filing claims.

Claims can be submitted electronically through an EDI 837 transaction using payer ID 71064 (HealthChoice) or payer ID 71065 (DOC and DRS). For direct data entry of claims, providers can use Optum Intelligent EDI (iEDI) by registering for the HealthChoice Provider Portal and creating an Optum One Healthcare ID. Providers can also upload claim images using PCH.

Optum Intelligent EDI registration

Optum Intelligent EDI (iEDI) is a fast, convenient and free option that can be used to directly enter claims online. To begin, select the iEDI claim submission option from the HealthChoice Provider Portal. This takes you to the Optum One Healthcare ID sign-in screen, where you can enter your One Healthcare ID and password. Signing in on this screen takes you to the UHC provider portal, where you can register your provider information with Optum. Follow the instructions in the Optum iEDI Registration User Guide for registration. Please email umr-business-edi@umr.com for assistance if you have any issues registering in the provider portal.

For issues registering with Optum One Healthcare ID (OHID), basic questions about OHID or assistance with unlocking OHID accounts, contact the Optum One Healthcare ID Help Center at 855-819-5909, visit the Help Center webpage or select “chat with support” at the bottom of the sign-in prompt.

Optum Intelligent EDI claim submission

Claims can be submitted electronically through an EDI 837 transaction using payer ID 71064 (HealthChoice). Optum – UMR’s clearinghouse for claims files – works with several clearinghouses to receive claims.

Once you are registered with the Optum iEDI platform, you can enter claims by following these steps:

1. Go to optum.com.
2. Sign in with your One Healthcare ID. Note that you are now signed in to the Optum iEDI platform and not UMR or UHC.

If you experience issues signing in to the Optum iEDI platform, please contact iEDI technical support at 866-678-8646 or Customer Care at toll-free 800-323-4314. When calling, make sure to provide your Optum ID (which is assigned to you when you register) and tell the customer service representative that you are a UMR/EGID provider and their Optum ID is inactive due to not logging in within the required time frame if your account has been locked. If you are not given help within 72 hours, please email umr-business-edi@umr.com for assistance.

DentalXChange

Dental claims can also be directly data-entered through DentalXChange.

If you are a dental provider using DentalXChange and need support, you can contact them at 800-576-6412 or submit an inquiry.

PCH

Claims images can be uploaded directly through the HealthChoice Provider Portal using the PCH claim submission option. This can be used for single-submission claims, supporting documentation, medical statements and records.

To register for this service, visit the PCH homepage:

1. Select My Account from the top menu bar.
2. Select Sign up from the drop-down menu that appears.
3. Complete the New Provider Registration form and select Submit.

This application does not support certification submission.

Claims can also be mailed to:

HealthChoice
P.O. Box 30511
Salt Lake City, UT 84130-0511

Department of Rehabilitation Services
P.O. Box 30521
Salt Lake City, UT 84130-0521

Department of Corrections Claims
P.O. Box 30522
Salt Lake City, UT 84130-0522

HealthChoice, DRS and DOC do not accept claims that are faxed or emailed.

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

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HealthChoice reimburses all ABA services at 149% of Medicaid rates.

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

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Oklahoma Senate Bill 442 requires all health plans to notify providers who have not filed a claim within 12 months. The health plan must terminate your contract unless you respond within 30 days indicating you wish to remain contracted.

Notices are emailed to providers and include any existing contracts with HealthChoice, DRS and DOC. This notice is sent annually to the contact person we currently have on file, if you have not filed a claim in the previous 12 months.

If you believe your contract was terminated in error, contact EGID Network Management. You must respond timely to any termination notices to avoid removal from network participation.

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

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When submitting medical records after a claim denial, please follow these suggestions to avoid misrouting or delays in processing:

• Submit only the requested documentation.
• Include a cover sheet with the claim number and member information.
• Whenever possible, use the HealthChoice Provider Portal to submit medical records.

Please visit the Claim denials for medical records section of the HealthChoice Providers Policies and Guidelines page for additional information on submitting medical records through the provider portal.

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

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HealthChoice covers qualified laboratory urine drug screenings once per day per patient. As a reminder, HealthChoice covers only the following laboratory urine drug screens when medically necessary screening tests are required.

Laboratory screening and confirmation services are covered under the HealthChoice medical plan, subject to deductible, coinsurance, out-of-pocket maximums, clinical editing and all policy provisions.

• Presumptive (qualitative) laboratory urine drug screenings are limited to 12 total per calendar year; certification is not required. 
  • 80305 - DRUG TEST PRSMV QUAL DIR OPTICAL OBS
  • 80306 - DRUG TEST PRSMV QUAL INSTRMNT OPTCL OBS
  • 80307 - DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS
• Definitive (quantitative) laboratory urine drug screenings are limited to four total per calendar year and certification is not required.
  • G0480 DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CL.
  • G0481 DRUG TEST DEFINITV DR ID METH P DAY 8-14 DRUG CL.
  • G0482 DRUG TEST DEFINITV DR ID METH P DAY 15-21 DR.
  • G0483 DRUG TEST DEFINITV DR ID METH P DAY 22/MORE DR CL.

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

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HealthChoice Select is available to all HealthChoice primary members Select provides specified services at no cost to the member.* These Select services must be performed on the same day with a Select provider and are bundled into one payment.

Advantages of being a Select provider include:

• Services are covered at 100% of bundled, allowable fees.*
• No coinsurance or deductible to collect.* 
• One bundled payment for the services performed on the same date.
• Potential to increase patient volume as there is no out-of-pocket cost for the member to receive services.* 
• Dedicated Select provider directory on the HealthChoice website.
• Targeted marketing to HealthChoice members to drive them to Select providers.
• Eligibility for the physical therapy clinic to group contract, meaning no more individual practitioner contracts.** 

Physical therapy clinics not joining Select will continue to contract providers individually.

To access applicable bundles and allowables, log in to the fee schedule portal, select the SELECT OUTPATIENT ASC Excel file and filter the procedure description column by Physical Therapy. Some bundles will still require certification.

To group-contract your physical therapy clinic and join the Select program, email EGID Network Management or call 405-717-8780 or toll-free 800-752-9475.

*Members of the HDHP must meet their deductible before any benefits, other than for preventive services, are paid by the plan.

**Group contracting is only available to those physical therapy groups who are eligible and sign up to become Select providers. To be eligible for group contracting, the clinic must primarily be involved in physical therapy. Occupational therapy or speech therapy are not currently eligible for group contracting or Select.

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HealthChoice, DOC and DRS are launching an updated version of the provider portal in September 2025. This update aims to provide a user-friendly way to access information efficiently. This improved online experience will provide users with an intuitive, user-friendly way to access benefits, claims, certification and appeals information quickly and easily.

Users will be able to log in using their existing HealthSafe or One Healthcare IDs and will not need to create new ones.

The previous gray side panels will be removed, creating more space for a clean, modern and simplified design. Additionally, portal content has been reorganized to be more intuitive by placing frequently used items previously available in the myMenu section into a horizontal navigation bar across the top of the dashboard homepage. Each category on the horizontal navigation bar has a drop-down menu, allowing providers to get the information they need, quickly and easily.

The new dashboard gives providers an in-depth view of information and quick access to provider resources, tools, and more.

Providers can send, receive and read emails through Optum secure messenger.

Featured prominently on the dashboard, the Patient search tool has been redesigned based on provider user feedback. It now requires fewer clicks and repeat searches. With one search, users can find all the information they need about a member, including what the member sees, such as coverage, benefits and claims.

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

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Availity and Change Healthcare can now send 275 EDI transactions for the following payers: HealthChoice, DOC and DRS. This update allows providers to submit supplemental documentation not included in the 837-claim file.

Use the following payer IDs for HealthChoice, DOC and DRS for claims processing:

• 71064 HealthChoice.
• 71065 DOC and DRS.

You will also need to use these group numbers:

• 76415077 HealthChoice (member IDs did not change).
• 76415170 Oklahoma DOC (member IDs include 365000 + DOC inmate ID number).
• 76415171 Oklahoma DRS.

Please refer to your clearinghouse for more information.

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Claims billed with evaluation and management (E&M) codes and billed with manipulative treatment will not be reimbursed separately unless billed with modifier 25 and medical records indicate that a significant and separate E&M service was performed. HealthChoice utilizes National Correct Coding Initiative (NCCI) edits to promote correct coding and prevent improper payment when incorrect code combinations are reported.

Modifier 25 identifies a service as significant and separately identifiable from other procedures performed on the same date of service. It should only be used in those instances where a service is separately identifiable and above and beyond the other services or where services are beyond the usual preoperative and postoperative care associated with the procedure.

Claims received with modifier 25 appended to an E&M code will initially deny requiring medical records submission to the appeals team. Once received, the claim is reopened. Do not submit a new claim. Medical records must be submitted through the HealthChoice Provider Portal for reconsideration. Once you sign in to the portal, select the Claim appeal submission button and follow the steps to submit the records with the appeal.

Alternatively, if you partner with any of the clearinghouses listed below, we can receive your records electronically with your claim upon initial submission for review on a prepay basis. This allows us to review the records prior to a denial being placed on the claim and alleviates the need to submit an appeal after the denial is received. Please contact your clearinghouse for additional information and to ensure this functionality is enabled.

• Availity
• CHC
• Claims MD
• Experian 
• Optum
• Quadax
• SSI
• Xifin

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

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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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