2026 Spring Network News

• Billing for DOC inmates
• DRS billing
• Telehealth services
• Timely filing and appeals
• Advanced claim review
• Medical records submission with initial claims and claim denials
• Reimbursement for applied behavioral analysis (ABA)
• CPAP and BiPAP supplies
• Drug Administration Policy
• Fee schedule updates
• HealthChoice contact information

To be reimbursed for medical or dental services provided to DOC inmates, you must bill the Department of Corrections within 120 days of providing services and adhere to following the directions below.

You may file claims electronically with payer ID 71065, through the provider portal (you can upload a claim with PCH or you can manually key a claim with iEDI), or mail paper claims to DOC Claims, P.O. Box 30522, Salt Lake City, UT 84130-0522.

• Bill with group number 76415170.
• Add the prefix 365000 to the DOC inmate ID number if it is 6 digits.
• Add the prefix 36500 to the DOC inmate ID number if it is 7 digits.
• Enter the updated prefix + digit DOC inmate ID number when making a DOC inquiry using the IVR system or provider portal.

The updated DOC inmate ID number, after adding the prefix, should always be 12 digits. To verify the DOC inmate ID number, visit https://okoffender.doc.ok.gov/.

You cannot invoice or balance bill the inmate for reimbursement. Invoices received by DOC or the inmate will be disregarded. DOC claims are paid at 100% of the fee schedule allowable. You can view allowable amounts for DOC claims by logging into the DOC Fee Schedule.

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

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You must file claims using industry-standard formats to be reimbursed for services performed on behalf of the Department of Rehabilitation Services. The claims administrator offers several different methods of claims submission:

• Electronically file claims with payer ID 71065.
• Direct data entry of medical claims is available through Optum Intelligent EDI (iEDI), available for free, to enter claims directly online, through the portal. DentalXChange is available for the direct data entry of dental claims.
• Upload claim images through the portal.
• Mail paper claims to DRS, P.O. Box 30521, Salt Lake City, UT 84130-0521.

You must use the group number 76415171 and include the members social security number in the insured’s I.D. number field on the claim form. Claims should be submitted on an appropriate claim form with all required fields completed and legible. Timely filing limits require the claim to be filed within 180 days of the date of service.

For general questions, call Customer Care at toll-free 800-285-6815. TTY users call 711.

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Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

The following is a comprehensive list of benefits for telehealth services available through network providers:

• HealthChoice covers telehealth services that may or may not be clinical in nature, including audio and video services at an originating provider site between a member and distant site provider.
• Institutional claims must include place of service (POS) 02 and indicate the GT or GQ modifiers to qualify for reimbursement.
• Professional services require the use of POS 02 or POS 10. Modifiers are not required. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance. 
  • POS 02 will be reimbursed using the facility rate on the Professional fee schedule.
  • POS 10 will be reimbursed using the non-facility rate on the Professional fee schedule.
• HealthChoice will acknowledge and pay telehealth claims according to the Professional or OP ASC fee schedule(s).
• HealthChoice excludes telepharmacy networks that use pharmacists to provide services.

All plan policies and provisions apply including HealthChoice claim editing guidelines.

For questions about eligibility, benefits, certification or claims, call Customer Care at toll-free 800-323-4314.

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All original claim submissions must be filed within 180 days from the date of service. Corrected claim submissions must be filed within 180 days from the original process date. Secondary and tertiary claim submissions must be filed within 180 days from the previous responsible carrier’s process date.

Each HealthChoice contract contains timely filing provisions. Claims can be filed electronically with payer ID 71064, through the provider portal (you can upload a claim with PCH or manually key a claim with iEDI), or by mail.

When claims are denied requesting additional information, you must provide the information within 180 days of the claim denial date. To submit the documentation in the portal, use the Document submission option under the myMenu Submissions section.

Any certification request denied in whole or part can be appealed within 180 days from the date of the denial. Any claim denied in whole or part can be appealed within 180 days of the date of the original claim denial, as documented on each remittance advice. If you are eligible for a second-level review, it must be filed within 90 days from the date of the first-level response.

To initiate your appeal and upload documentation through the portal, use the Claim appeal submission option.

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

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HealthChoice utilizes Advanced Claim Review (ACR), a program that 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 you could experience with claim editing:

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

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

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PCH is the claims submission vendor for UMR, the claims processor for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS).

The PCH portal allows you to submit medical records during your initial claim submission. For help with the PCH tool, select the Contact Us option on the login screen.

What to expect with claims denied for medical records:

• By referencing the ineligible code, you will see the claim was denied for medical records on your HealthChoice remittance advice (RA).
• You may receive a letter, in addition to your RA, telling you why the claim was denied and what records are needed to complete the review of the claim, including details on what is needed and where and how to submit the records back to UMR.

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

• Submit only the requested documentation.
• Whenever possible, use the HealthChoice Provider Portal to submit medical records. Under the Provider center, on the home screen, select the Document submission link. You will need to include the claim number and patient information.
• If submitting medical records by mail, include a cover sheet with the claim number and patient information.

For questions, call the Customer Care team 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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HealthChoice requires providers to indicate the name of the drug being administered on claim submissions, even if reimbursement is not being requested for the drug. HealthChoice will not pay for the administration charge unless the drug being administered is covered and medically necessary. If the provider is billing drug-related revenue, HCPCS or CPT codes, the claim must indicate the drug's national drug code (NDC), quantity and unit of measure.

This policy applies to all professional and hospital outpatient claims containing drug-related revenue, HCPCS or CPT codes which must be billed with the NDC indicated on the container from which the medication was administered. The NDC is not required for G codes and P codes, routine childhood and adult immunization drug codes. The NDC must be 11 digits (5 digits-4 digits-2 digits) in order for it to be accepted; however, there are times when the NDC on the container does not contain 11 digits. In this case, you will add preceding zeroes to the section of the N DC that does not follow the 5-4-2 format.

The drug-related revenue, HCPCS or CPT codes will need to indicate the number of units for reimbursement purposes as defined in the description of the code being billed. You must include the NDC units to report the units being administered. Both are required on the claim for accurate reimbursement. To bill NDC units, the unit of measurement and the quantity (including decimals) are required. Acceptable units of measurement are GR for gram, ML for milliliter, UN for unit, and international unit F2. For example, if the provider administers two .75 milliliter vials, you would report Mll.5.

You may have multiple NDCs when you administer multiple drug strengths to a patient or when a drug is comprised of more than one ingredient. Submit each NDC number as a separate claim line with the appropriate revenue, HCPCS or CPT drug code. There are standard billing modifiers to use when there is more than one NDC for a service code. For paper claims, use KP (the first drug of a multiple drug formulation) and KQ (the second or subsequent drug of a multiple drug formulation). For electronic claims, report compound drugs by repeating the LIN and CPT segments in loop 2410. If the box for the drugs contains more than one medication, use the NDC number found on the box. However, if the box for the drugs contains multiple vials of the same medication, use the NDC number found on the vial. There are exceptions when drug manufacturers don't provide pricing at the individual vial level. Generally, only NDC numbers with available pricing are considered valid. In these instances, you should bill using the NDC information from the outside packaging and include the correct units administered.

CMS 1500 form:

• Enter the NDC information in field 24. There are six service lines in field 24 with shaded areas.
• Place the NDC information in the line's top shaded part.
• Enter any supplemental NDC information in the following order: 
  • N4 qualifier.
  • 11-digit NDC code.
  • Add one space.
  • Two-character unit of measurement and quantity.

UB-04 form:

• Field 42: Include the appropriate revenue code.
• Field 43: Include the 11-digit NDC code, unit of measurement and quantity.
• Field 44: Include the HCPCS code if required.

EDI requirements for professional (837p) and institutional (837i) claims:

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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.

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.

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