In this issue...
Reimbursement for proprietary lab service codes
Effective Jan. 1, 2027, HealthChoice will reimburse providers for proprietary lab service codes (XXXXU) at 100% of current Medicare rates.
For questions, email EGID Network Management or call us at 405-717-8780 or toll-free 800-752-9475.
Reimbursement for radiology service codes
Effective Jan. 1, 2027, HealthChoice will reimburse providers for radiology service codes at 138% of current Medicare rates.
For questions, email EGID Network Management or call us at 405-717-8780 or toll-free 800-752-9475.
DRS rate improvements coming in 2027
The Department of Rehabilitation Services (DRS) is currently reviewing opportunities to improve its fee schedule rates. DRS recognizes that some of their current reimbursement rates are low and are actively working toward increasing fees in the near future.
DRS appreciates your continued partnership and commitment to serving its clients. Please continue to watch the Network News for additional information and updates regarding improvements anticipated in 2027.
Current fee schedule rates are available on the DRS provider site.
If you have questions or need additional information, please email or call 888-835-6919.
CPAP and BiPAP supplies
HealthChoice covers supplies for continuous positive airway pressure (CPAP) machines and bilevel positive airway pressure (BiPAP) machines.
Supplies are reimbursed separately, subject to plan provisions. The frequency limits for covered unit supplies are dictated as follows:
| HCPCS code | HCPCS code description | Replacement frequency |
|---|---|---|
A4604 | CPAP Tubing with Heating Element | 1 per 3 months |
A7027 | Combination Oral/Nasal CPAP Mask | 1 per 3 months |
A7028 | Replacement Oral Cushion for Oral/Nasal Mask | 2 per 1 month |
A7029 | Replacement Nasal Pillows for Oral/Nasal Mask, One Pair | 2 per 1 month |
A7030 | Full Face Mask | 1 per 3 months |
A7031 | Full Face Mask Interface | 1 per 1 month |
A7032 | Cushion for Nasal Mask Interface | 2 per 1 month |
A7033 | Nasal Pillows | 2 per 1 month |
A7034 | Nasal Interface | 1 per 3 months |
A7035 | Headgear | 1 per 6 months |
A7036 | Chinstrap | 1 per 6 months |
A7037 | Tubing | 1 per 3 months |
A7038 | Disposable Filter | 2 per 1 month |
A7039 | Non-disposable Filter | 1 per 6 months |
A7046 | Humidifier Water Chamber | 1 per 6 months |
For questions about eligibility, benefits, certification or claims, call Customer Care at toll-free 800-323-4314.
Anesthesia modifier updates
MS-DRG and MS-DRG LTCH Fee Schedules: Version 44 updates
The HealthChoice and Department of Corrections annual MS-DRG updates to acute inpatient reimbursement include updates to tier designations based on the number of beds and designated provider type as urban or rural as contained within the current year’s final IPPS file.
MS-DRG
For charges incurred on or after Oct. 1, 2026, the following changes are effective for the HealthChoice and DOC MS-DRG Fee Schedules:
| Tier | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Base Rate | $13,913 | $12,863 | $13,277 | $12,685 |
| Marginal Cost Factor | 0.20 | 0.28 | 0.32 | 0.45 |
| Threshold | $318,299 | $206,356 | $190,887 | $164,841 |
The market basket update factor is 2.3%.
The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2027.
LTCH-DRG
For charges incurred on or after Oct. 1, 2026, the following changes are effective for the HealthChoice and DOC LTCH DRG Fee Schedules:
- Version 44 of the LTCH DRG Fee Schedule has a base rate of $62,559.00. The outlier threshold is $78,936.00, while the cost-to-charge ratio is 0.203.
The next comprehensive LTCH DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2027.
If you have any questions regarding these adjustments, email EGID Network Management or call 405- 717-8780, toll-free 800-752-9475. TTY users call 711.
Fee schedule updates
Future fee schedule updates for services by HealthChoice network providers are scheduled for:
| ANNUAL FEE SCHEDULE RELEASES | JAN. 1 | APRIL 1 | JULY 1 | OCT. 1 |
|---|---|---|---|---|
| Anesthesia (ASA) | Comp | |||
| Bariatric Surgery - Inpatient | Comp | A/C/D | A/C/D | A/C/D |
| Bariatric Surgery - Outpatient | Comp | A/C/D | A/C/D | A/C/D |
| Dental (ADA) | Comp | A/C/D | A/C/D | A/C/D |
| Diabetes Prevention Program (DPP) | Comp | |||
| Endodontic | Comp | A/C/D | A/C/D | A/C/D |
| MS-DRG | Comp | |||
| MS-DRG LTCH | Comp | |||
| NDC | Comp | Comp | Comp | Comp |
| Outpatient (w/ASC, ASC Implants, and Non-CMS Certified) | Comp | Comp | Comp | Comp |
| Outpatient Revenue | Comp | A/C/D | A/C/D | A/C/D |
| Preventive Services | Comp | A/C/D | A/C/D | A/C/D |
| Professional (CPT and HCPCS) | A/C/D | Comp | A/C/D | A/C/D |
| Select Inpatient (MS-DRG) | A/C/D | A/C/D | A/C/D | A/C/D |
| Select Outpatient/ASC | A/C/D | A/C/D | A/C/D | A/C/D |
*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. Also updated on Oct. 1 is the MS-DRG and MS-DRG LTCH base rate, factor and outlier threshold. 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.
For purposes of reimbursement, EGID defines Professional Services as CPT codes 90785 to 99999. EGID to reimburse PA, APRN-CNP, CNM or CNS practitioners billing independently under their own NPI number within the scope of their practice at the physician fee schedule rate, except for Professional Services (90785-99999) which are calculated at 85% of the allowable.
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.
HealthChoice contact information
Network Management Medical and Dental Claims, Eligibility, Benefits and Certifications New Claims, Correspondence and Medical Records Optum Pay | Pre-Service Appeals Post-Service Appeals Pharmacy Benefit Administrator: CVS/Caremark SilverScript (Medicare Part D)
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