2026 Winter Network News

• HealthChoice reimbursement for behavioral health licensure candidates
• Pre-payment audits of claims with emergency department billing codes
• MS-DRG and MS-DRG LTCH Fee Schedules: Version 43 updates
• HealthChoice additional payment vendor
• Fee schedule updates
• HealthChoice contact information

As a reminder, HealthChoice will only reimburse services provided by a behavioral health licensure candidate when all the following requirements are met:

• A licensed clinician is physically present in the room during the counseling session.
• The supervision is clearly documented in the medical record.
• The medical record is cosigned by the supervising licensed clinician.

Claims submitted by licensure candidates must be billed under the supervising licensed clinician’s NPI number. Claims that do not meet these requirements may be denied.

For inquiries about contracting or network status, email EGID Network Management, or call 405-717-8780 or toll-free 800-752-9475.

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

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The third-party administrator for HealthChoice is performing more extensive audits of facility claims filed with emergency department visit billing codes. If your claim is selected for an audit, it will be denied requesting medical records to ensure the records substantiate the level of care being billed.

If the medical records do not substantiate the level of care billed, the claim will be adjusted to reflect the appropriate lower level of care.

If you disagree with the adverse determination made during the audit, you may file an appeal and submit any additional documentation through the provider portal using the claim appeal submission option.

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

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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, 2025, the following changes are effective for the HealthChoice and DOC MS-DRG Fee Schedules:

The market basket update factor is 3.3%.

The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2026.

MS-DRG LTCH

For charges incurred on or after Oct. 1, 2025, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH Fee Schedules:

• Version 43 of the MS-DRG LTCH Fee Schedule has a base rate of $60,989.00. The outlier threshold is $78,936.00, while the cost-to-charge ratio is 0.211.

The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2026.

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.

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Effective Feb. 1, 2026, HealthChoice will offer electronic payments with payment vendor ZelisTM in addition to Optum FinancialTM (Optum Pay/VPay).

Providers currently enrolled with Zelis ACH+ will not need to make any changes. Enrollment with both Zelis ACH+ and Optum Financial will mean your payments will default to Zelis ACH+.

If you are currently enrolled with Zelis virtual cards and not enrolled with Optum Financial, you will start to receive virtual card payments through Zelis.

For questions about EFT payments, call Optum Pay at 877-620-6194; call Zelis Payments at 877-828-8770. 

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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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