Skip to main content

Policies and Guidelines

HealthChoice is a managed health care program providing comprehensive health and dental benefits to over 186,000 state, education and local government employees, former employees, survivors and their covered dependents.

HealthChoice is administered by the Office of Management and Enterprise Services Employees Group Insurance Division (EGID). The HealthChoice plans are a partnership between providers, members and EGID in the delivery of health and dental care services and products that helps control costs, assists in the provision of high-quality health and dental care, and enhances provider-patient relationships. The HealthChoice benefit structure offers financial incentives to encourage plan members to utilize HealthChoice network providers.

EGID provides health and dental care benefits in accordance with the provisions of Oklahoma Statutes, (74 O.S. 2012, §§ 1301, et seq.). The information provided in this manual is a summary of the benefits, conditions, limitations and exclusions of the HealthChoice High, High Alternative, Basic and Basic Alternative health plans, High Deductible Health Plan (HDHP) and the HealthChoice Dental Plan. It should not be considered an all-inclusive listing.

While the HealthChoice Network Provider Manual is a summary only and is not intended to be all-inclusive, its contents should offer providers and their staff vital information regarding the most important aspects of the provider network.

Plan benefits are subject to conditions, limitations and exclusions described and located in Oklahoma Statutes, Administrative Rules, and Administrative Procedures adopted by the plan administrator. You can obtain a copy of the official rules from the office of the Oklahoma Secretary of State. An unofficial copy of the Administrative Rules is available on this website. 


HealthChoice encourages ambulatory surgery centers to bill facility charges on a form UB-04 or through 835i electronic claims. However, HealthChoice will accept facility charges when billed on a CMS 1500 form as outlined below.

When an ASC bills both the professional and ambulatory surgery center charges on a CMS 1500 form, it can be difficult to distinguish between the two.

To ensure that ASC claims and professional claims are paid as separate services and at the correct rates, providers should follow these guidelines when billing a CMS 1500 form:  

  • Ensure that the ASC claim does not include the rendering provider’s Type 1 NPI. On a CMS 1500 form, this information is often included in field 24. However, for ASC claims, you should leave field 24J blank.
  • Include all facility information in box 33 and the ASC’s NPI in field 33a; this is the billing provider information.
  • Add an SG modifier to the first modifier field for service codes. The SG modifier distinguishes the claim as an ASC claim (facility claim).
  • Use the place of service indicator for an ASC; this is place of service 24.

For questions about ASC facility billing, contact the medical and dental claims administrator at toll-free 800-323-4314.


HealthChoice covers specific bariatric surgical procedures subject to certification and clinical criteria and guidelines set forth by the Certification Administrator. These procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP) Comprehensive Center of Excellence contracted with HealthChoice as a network facility provider. 

The benefit also includes related pre-operative and workup services. All covered procedures and related services are subject to plan provisions including member liability for copay, coinsurance and deductible amounts. The covered procedures are: 

  • Sleeve.
  • Bypass.
  • Duodenal switch.
  • Revision and conversions of a sleeve, bypass or duodenal switch procedure when medically necessary. The initial bariatric surgical procedure must have been performed according to one of the following:
    • As part of the HealthChoice bariatric surgery pilot program, dates of service Jan. 1, 2013, thru Dec. 31, 2017.
    • Under the HealthChoice plans on or after Jan. 1, 2017.

The bundled allowed amount includes the facility, surgeon, assistant surgeon, anesthesiology, laboratory, pathology, radiology and other related services when those services are rendered on the same date or during the hospital confinement. These services are subject to bundled reimbursement methodology and plan provisions including member liability for copay, coinsurance and deductible amounts. 

To be eligible for the benefit, participants must be a HealthChoice member, spouse or child, age 18 or older, with no other primary coverage. 

  • The participant must be covered under a HealthChoice health plan for 12 consecutive months prior to bariatric surgery regardless if the member has been eligible under other plans offered by EGID.
  • The participant will be encouraged to continue health coverage with HealthChoice for 24 months post-surgery.
  • The participant must meet specific criteria, which includes, but is not limited to, severity of obesity, reliable participation in preoperative weight-loss program that is multidisciplinary, and expectation of adherence to postoperative care.

The following services are not covered: 

  • Band and band revisions.
  • Bariatric surgical services obtained from any facility that is not a HealthChoice bariatric network provider.
  • Revisions to bariatric surgical procedures originally obtained during a time when the individual was not covered by HealthChoice.
  • Revisions to bariatric surgical procedures originally obtained from a facility that was not a HealthChoice bariatric network provider.
  • Related workup and postoperative services billed with a diagnosis code of obesity (ICD-10 code E66).


HealthChoice utilizes combined payments for all providers. Under the combined payments feature, all payments for a given day are combined into a single remittance advice for a single provider. Combined payments facilitate the processing of claim payments for providers. If you have questions or you need more information, contact the medical and dental claims administrator for assistance.


Under the terms of the network provider contract, the coordination of benefits rules are subject to change. HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Following is a brief description of the rules that apply: 

  • Allowable expense is a health care expense, including deductibles, coinsurance and copayments, covered at least in part by any plan covering the person. An expense not covered by any plan covering the person is not an allowable expense. Any expense that a provider is prohibited (by law or by contract) from charging a covered person is not an allowable expense.
  • The benefits paid by medical and dental plans will equal no more than the allowable expense.
  • The amount of any benefit reduction by the primary plan because a covered person has failed to comply with the plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and failing to use the primary plan’s preferred provider arrangements.
  • HealthChoice shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
  • There is no “lesser of” calculation involving the primary carrier and HealthChoice allowable amounts or of what HealthChoice would pay in the absence of other health care coverage. If the primary carrier paid zero on the entire claim, then HealthChoice will pay its normal benefits (unless bullet 3 applies).
  • The only amount updated in the out-of-pocket max bucket is the true OOP the member has to pay, excluding charges for non-covered services, balance billing charges from non-network providers and amounts paid by third parties.
  • HealthChoice requires verification of other insurance on a rolling 12-month basis.


HealthChoice allows the billed charge or allowed amount, whichever is less, of the set copay up to the out-of-pocket maximum. All provider remittance advices and 835 transactions will reflect the accurate copay amount. (Effective Jan. 1, 2017)


A dental predetermination is an itemization of proposed dental charges and their reimbursements before dental services are performed. It should not be confused with certification. A predetermination is not required, but is recommended when the dental treatment plan proposed by the provider is expected to exceed $200. A predetermination also shows the financial liability of the member. It should be identified as a predetermination and submitted in the same manner as a standard paper dental claim or HIPAA 837 electronic claims submission.


CPT code 21248 is for partial restorations using implants involving less than half of the arch, while 21249 is for complete restorations involving more than half of the arch. Do not report these codes for each implant. Only report one instance of the applicable code, and report the number of implants placed in the “units” column.

Certification is required.


HealthChoice has implemented a benefit for coverage of the Centers for Disease Control and Prevention (CDC)-recognized National Diabetes Prevention Programs (DPPs) and is contracting with provider organizations in Oklahoma that have achieved full CDC recognition. The CDC National DPP is a lifestyle change program that offers evidence-based, cost-effective interventions that help prevent type 2 diabetes. The program is intended to create behavioral changes to improve healthy eating, increase physical activity and manage stress. 

Participation in the program is offered as a preventive service. HealthChoice covers qualifying preventive care services at 100% of allowable fees for a qualifying code when rendered by a participating network provider. There are no copays, deductibles or coinsurance applied under this benefit.  

All HealthChoice participants who meet DPP eligibility as established by a participating DPP provider are eligible for one year in the program. Members who successfully meet the year one performance goal will be eligible to continue participation in ongoing maintenance sessions through year two.  

To locate a network DPP, visit the HealthChoice Provider Search site at and search by specialty. 

For additional information, call EGID Network Management at 405-717-8790 or toll-free 844-804-2642. 


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 NDC 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 ML1.5. 

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: 

Loop Segment Element name Information  
2410 LIN 02 Product or service ID qualifier. If billing for an NDC, enter N4.
2410 LIN 03 Product or service ID qualifier. If billing for drugs, include the 11-digit NDC.
2410 CTP 04 Quantity. If an NDC was submitted in LIN03, include the administered NDC quantity.
2410 CTP 05-1 Unit or bases for measurement code. If an NDC was submitted in LIN03, include the unit or basis for measurement code for the NDC billed. See Q6 for unit information.
2410 REF 01 VY: link sequence number.XZ: prescription number. The link sequence number is used to report components for compound drug.
2410 REF 02 Link sequence number or prescription number.  


For DME rental charges incurred Jan. 1, 2018, and after, the provider is required to submit the purchase price when the HealthChoice allowed amount is $100 or more. HealthChoice will deny these claims when the purchase price is not included.

If you have questions, call the medical claims administrator at 800-323-4314.


HealthChoice utilizes the 835 electronic remittance advice crosswalk table, which consists of claims adjustment reason codes (CARC), remittance advice remake codes (RARC) and explanation codes that are associated with claims processing.


The HealthChoice Provider Network is comprised of over 26,000 medical and dental care practitioners and facilities. Most providers who are licensed and/or certified in their particular state are eligible to participate in the provider network. HealthChoice plan members have the ability to use health care providers from a wide range of specialties. The following specialties are eligible to participate in the HealthChoice Provider Network:



Licensed Alcohol and Drug Counselor

Ambulatory Surgery Center

Licensed Behavioral Practitioner

Anesthesia Groups

Licensed Clinical Social Worker

Anesthesiology Assistant

Licensed Genetic Counselor


Licensed Marriage Family Therapist

Birthing Center

Licensed Professional Counselor

Board Certified Assistant Behavioral Analyst

Long-term Acute Care Facility

Board Certified Behavioral Analyst

Medical Doctor

Cath Lab

Mental Health/Substance Abuse Facility

Certified Nurse Midwife


Certified Orthotist

Occupational Therapist

Certified Nurse Practitioner


Certified Prosthetist


Certified Registered Nurse Anesthetist

Oral Surgeon


Osteopathic Doctor

Christian Science Nurse

Pathologist (Individual)

Christian Science Practitioner

Pathology Group

Clinical Nurse Specialist




Diabetes Prevention Program Organization

Physical Therapist

Dialysis Center



Physician Assistant

Durable Medical Equipment Vendor


Emergency Physician Group


Hearing Aid Vendor

Radiologist (Individual)

Home Health Care Agency

Radiology Group

Home Hospice Agency

Registered Behavior Technician

Hospice Facilities

Rehabilitation Facility


Skilled Nursing Facility

Hospitalist Group

Sleep Study Provider

Independent Diagnostic Testing Facility

Speech Language Pathologist

Infusion Therapy Center

Urgent Care Clinic



Refer to agency rules and HealthChoice contracts for specific requirements. 
The contracts require network providers to make a reasonable effort to refer HealthChoice members and their dependents to other network providers when additional consults are necessary. EGID believes this referral process is in the best interest of the plan member and within the dictates of good medical practice. Plan members cannot realize the full benefit of their HealthChoice plan unless they utilize network providers. HealthChoice also provides network reimbursement to rural health clinics, federally qualified health centers, Veterans Health Administration facilities, military facilities, city/county health departments, Indian Health Services facilities, radiation therapy centers and Metabolic Bariatric Surgery Accreditation and Quality Improvement Program Comprehensive Centers of Excellence. You can obtain contract applications through the HealthChoice Network Provider website or by contacting HealthChoice Network Management.


  1. This procedure describes the exclusive method of initiating any disputes related to HealthChoice Network Facility Contracts and Network Provider Acute Care Facility Contracts. The submission of a Request for Dispute Resolution Form to HealthChoice will signify good faith acceptance and agreement with all of the terms herein.
  2. The initiation of a dispute shall not require a party to delay or forego taking any action that is otherwise permitted by the network contract.
  3. HealthChoice has adopted this policy to provide a consistent method for the resolution of disputes with network facilities.
  4. Facilities who wish to dispute a decision by the HealthChoice Appeals Unit can submit a Request for Dispute Resolution within 45 days of the Appeals Unit’s final adverse determination. If not timely filed, the request will not be considered, and the matter will be deemed finally resolved. HealthChoice will have 45 days after submission to reach a determination.
  5. All Requests for Dispute Resolution must be submitted with a properly completed HealthChoice Request for Dispute Resolution Form. Forms must be mailed to HealthChoice at the address shown on the Form. Requests involving multiple similar claims must be accompanied by a spreadsheet including pertinent information on all claims. Requests submitted with insufficient supporting documentation will be returned.
  6. HealthChoice will not discriminate or retaliate against any facility due to participation in the Dispute Resolution process. All rights and conditions set out in the network facility contract will apply to the parties at all times, regardless of the existence of a Request for Dispute Resolution between the parties.
  7. Facilities are not permitted to pursue dispute resolution on behalf of a member or dependent. Facilities have agreed by contracting with HealthChoice that the permitted and non-permitted matters subject to this dispute resolution procedure are limited and listed in the network facility and Network Provider Acute Care Facility contracts at Section X. Dispute Resolution, paragraph 10.1. Facilities are not permitted to pursue, initiate or continue this dispute resolution process when the member or dependent timely exercises or has exercised their legal right to appeal the same claim or service that gives rise to the dispute specified by the facility.


EGID recognizes your need for fee schedule information in order to conduct financial impact assessments. For your convenience, access to current HealthChoice fee schedule information is available to network providers through the HealthChoice Network Provider website at  

Disclaimer: This fee schedule is not 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.


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

Date   ASC ADA ASA Bariatric  CPT HCPCS MS-DRG MS-DRG LTCH OP Select inpatient Select outpatient/
Jan. 1 A/C/D Comp Comp  A/C/D A/C/D A/C/D     Comp A/C/D Comp
April 1 Comp A/C/D   A/C/D Comp Comp     Comp A/C/D A/C/D
July 1 A/C/D A/C/D   A/C/D A/C/D A/C/D     Comp A/C/D A/C/D
Oct. 1 A/C/D A/C/D   Comp A/C/D A/C/D Comp Comp Comp Comp A/C/D

*Comp – Comprehensive                     
*A/C/D – Adds, changes, deletes and other necessary updates

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

Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1, based on the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the ZIP code of its physical location which is included in the U.S. Census Bureau’s metropolitan core-based statistical area. On Jan. 1, the urban/rural indicator will be 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.

Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the program will become fully phased in during the next quarterly update. 

Fee schedule updates are reported in each quarterly issue of the Network News newsletter. If you need specific codes and allowable fees affected by these updates, please visit our fee schedule website and view or download the latest fee schedule addendum. 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. If you have questions or need additional information, please contact network management.

The following terms are used in the fee schedule: 

  • BR: by report.
  • BR1: 60% of billed charges for Tiers 1 and 2; 70% of billed charges for Tiers 3 and 4.
  • BR2: 30% of billed charges for Tiers 1 and 2; 35% of billed charges for Tiers 3 and 4.
  • BR3: 0% of billed charges for Tiers 1, 2, 3 and 4.
  • Health: submit to health plan.
  • I: incidental.
  • IC: individual consideration.
  • NC: non-covered.
  • NOC: non-classified drugs.
  • Per Diem: per diem rate.
  • RX: submit to pharmacy administrator.
  • TM: use of time.
  • Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee.
  • Anesthesia conversion factors (2020).
    • $59 CRNA.
    • $62 M.D./D.O.
    • Anesthesia assistant is 50% of allowable fee.


The HealthChoice pharmacy network includes both independent and national chain pharmacies. There is also the option of mail service. Members can fill prescriptions for up to a 90-day supply at all HealthChoice network pharmacies at the same cost as using mail service.

For details regarding HealthChoice pharmacy benefits, including lists of commonly prescribed medications, excluded medications with preferred alternatives and specialty medications, visit the HealthChoice Pharmacy Benefits Information page.

For information regarding network pharmacies and medication lists, call the pharmacy benefit manager toll-free at 877-720-9375. TTY users call 711.


HealthChoice Select is a program designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed.

HealthChoice would like your facility to be part of the HealthChoice Select program. 

HealthChoice Select continues to increase the services covered under the program to include more of those with reasonably controllable cost variances, high consumer demand and market growth.

Advantages of participating in HealthChoice Select include: 

  • Procedures covered at 100% of allowable fees.*
  • No copays, coinsurance or deductibles to collect.*
  • Approximately 170,000 HealthChoice members in or near Oklahoma.
  • Potential to increase patient volume.
  • Dedicated provider directory on HealthChoice website.
  • Targeted marketing to HealthChoice members.

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

Colonoscopies and sigmoidoscopies are covered under the program. To encourage members to participate in HealthChoice Select for these services, HealthChoice provides a $100 incentive payment to members.

For a list of services and procedures covered under HealthChoice Select, log in and access the Select fee schedule at You can also search for a list of services and procedures available through HealthChoice Select at

Be aware that participating facilities are not required to provide all of the services covered under the program. Facilities can choose any combination of services and opt in or opt out at any time, according to existing contract notification provisions. 

To participate in HealthChoice Select, facilities must agree to and sign the contract amendment listed below for each location choosing to participate. Network management will provide the Attachment A with applicable services upon request.

For more information about participating in HealthChoice Select, please call network management at 405-717-8790 or toll-free 844-804-2642 or email

Other Helpful Links:

HealthChoice Select


HealthChoice Radiology and Sleep Study Facility Contract and First Amendment Select Amendment
HealthChoice Independent Diagnostic Testing Facility Amendment
HealthChoice Select Facility Amendment
HealthChoice Select Network Ambulatory Surgery Center Amendment


EGID has established a four tier system for short-term acute facilities:

  • Tier 1 – Network urban facilities with greater than 300 beds.
  • Tier 2 – All other urban and non-Network facilities.
  • Tier 3 – Critical access hospitals (CAH), sole community hospitals (SCH), Indian, military and VA facilities.
  • Tier 4 – All other Network rural facilities.

Annual updates to the base rate:

  • Tier 1 and Tier 2 – 100 percent of Medicare’s full market basket percentage.
  • Tier 3 – 50 percent of Medicare’s full market basket percentage.
  • Tier 4 – Remain frozen. For short-term acute facilities, Tier 4 remains frozen until Tier 2 base rate exceeds Tier 4.
  • Base rates will be reevaluated annually.

HealthChoice utilizes the Centers for Medicare & Medicaid Services (CMS) local coverage determination guidelines for approval of intraoperative neurophysiologic monitoring claims.

View the most current version of LCD guidelines for IONM (L35003) by reviewing and accepting the CMS License Agreements.  


Providers will receive one 1099 for each tax identification number. Even if you share a TIN with other providers, only one 1099 will be sent. This form will be addressed to the name registered with the Internal Revenue Service and mailed to the address indicated on your Form W-9.


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:

  • 80300 – Drug Screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures (e.g., immunoassay) capable of being read be direct optical observation, including instrument-assisted when performed (e.g., dipsticks, cups, cards, cartridges), per date of service.
  • G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter.

Clinical editing applies.

HealthChoice covers the following presumptive (qualitative) and definitive (quantitative) laboratory urine drug screenings when medically necessary. 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.
  • Definitive (quantitative) laboratory urine drug screenings are limited to four total per calendar year and certification is not required.

If you have any questions regarding this change, please contact our medical claims administrator.


HealthChoice is contracted with SilverScript to provide Medicare Part D benefits. Providers should contact SilverScript when a member needs a medication not listed in the HealthChoice SilverScript Medicare Formulary.

This is an example of the Medicare Part D Identification Card:


You can find a description of the plans offered by HealthChoice in the member handbooks.


MS-DRG and MS-DRG LTCH Version 40 Fee Schedule 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 provider type designation as urban or rural as contained within the current year’s final IPPS file.


For charges incurred on or after Oct. 1, 2022, the following changes are effective for the HealthChoice and DOC MS-DRG Fee Schedules:

Tier 1 2 3 4
Outlier Threshold $189,555  $140,788 $107,949 $109,155
Marginal Cost Factor 0.31 0.35 0.45 0.45
Base Rate $12,266 $11,396 $12,304 $10,824

The market basket update factor is 4.3%.

The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2023.


For charges incurred on or after Oct. 1, 2022, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH Fee Schedules: 

  • Version 40 of the MS-DRG LTCH Fee Schedule has a base rate of $59,195.00. The outlier threshold is $38,518.00, while the cost-to-charge ratio is 0.224.

The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2023. 

If you have any questions regarding these adjustments, call Network Management at 405-717-8790 or toll-free at 800-543-6044. 


Effective April 1, 2020, there are CPT/HCPS codes identified with an NDC status indicator on the CPT, HCPCS and Outpatient fee schedules. Reference the NDC and procedure code combination on the NDC fee schedule for the allowable fee. Bill with the NDC code and the corresponding CPT/HCPCS code.


The Network News newsletter is the primary information source for HealthChoice Network Providers, delivering plan reminders and updates quarterly. Each issue meets notice requirements as set out in section XII of the Network Provider Contracts.

EGID distributes electronic versions of the newsletter and other communications to network providers from To make sure you do not miss the newsletter or other communications, add this new email address to your safe senders list. 


The network management unit is responsible for developing the content of the Network News newsletter. This newsletter is a quarterly publication specifically for network providers. The newsletter contains the latest information regarding plan benefits, contracts and fee schedules. The newsletter also serves as the primary method by which providers receive notifications mandated by the terms of the provider contracts.

To distribute the newsletter as efficiently as possible, it is distributed electronically to each network provider’s correspondence email address. Email addresses are obtained through information submitted on contract applications. Network management also updates email addresses on a regular basis as providers submit current information connected with their practice locations.

To update email information, network providers can use the appropriate change form located on the Provider Forms webpage. Completed forms can be submitted to network management by mail, fax or email.

It is imperative providers inform network management when contact information of any type is updated. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. The HealthChoice email address should be added to the safe contact list so network management emails are not returned as undeliverable.

Printed newsletters are sent via the postal service to the mailing address on record for providers without internet access or those who have undeliverable email addresses.


The network provider contract gives EGID and the network provider the ability to terminate a contract with or without cause upon a 30-day written notice. Network providers must provide a termination notice in writing, facsimile or via email to A confirmation notice, to the provider, will be emailed or mailed to the mailing address on record. The termination will become effective on the date indicated on the confirmation. 

A provider is terminated immediately if their license is suspended or revoked or if their professional liability insurance is cancelled or not maintained in accordance with the network provider contract.

A network provider terminating with or without cause from the HealthChoice network is prevented from recontracting with HealthChoice for a period of 12 months following the effective date of termination, unless exceptional circumstances as determined by EGID Network Management require HealthChoice to execute a new contract. 

Please make a reasonable effort to inform all of your HealthChoice patients about your termination so they can make informed decisions about future provider utilization.


Members and providers have the option to nominate a medical or dental provider who is not a member of the HealthChoice Provider Network by submitting basic information on the provider search webpage.

Members and providers can also nominate facilities already participating in the HealthChoice Provider Network to be part of the HealthChoice Select program. The Select program is designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed. Only facilities can participate in HealthChoice Select, not individual practitioners.  

The contracting process may take at least several weeks. The provider or facility must satisfy our business requirements and meet our contracting standards. Nomination does not guarantee the provider or facility is eligible for participation in the network or will agree to contract with us. 


EGID CY2018 Outpatient Hospital Reimbursement Fee Modeling for Cases with CMS J1 Status Indicators Using CMS J1 Methodology 


Under the CMS Hospital Outpatient Prospective Payment System OPPS, CPT codes assigned a J1 modifier in the CMS OPPS Addendum B are assigned to a comprehensive APC (C-APC). The single payment for the C-APC includes all services and items included on the outpatient claim. There are a few carve-out items that receive separate reimbursement. The C-APC is assigned based on the primary CPT code with a J1 modifier. A complexity adjustment is made for certain combinations of primary and secondary CPT codes.

EGID Application of CMS Policy

A) EGID will be applying similar bundling logic to its outpatient hospital claims beginning Jan. 1, 2019. Claims with at least one CPT code that have a CMS J1 status indicator will be bundled into a single unit reimbursement for the primary J1 CPT code. The following procedure/items will be bundled into the payment for the primary procedure:

  • Secondary procedures in the CPT range 10000-69999 or 92900-93999 (with or without aJ1 status indicator).
  • Units for the primary J1 procedure beyond 1.
  • Services that are typically bundled for hospital outpatient surgery claims under EGID’s April 2018 Outpatient Fee Schedule. Examples include: NC – non-covered services, UB-revenue code items without a valid CPT code, and CPT codes that are assigned a $0 fee.
  • Implants that are billed with just a UB-revenue code are not paid separately and are bundled into the J1 procedure fee.
  • All other items, procedures or services that CMS does not specifically carve-out as a pass-through for J1 reimbursement (i.e., most lab, radiology, drugs and supplies will be bundled into the J1 procedure reimbursement).

B) The following items will be paid separately in accordance with the CMS methodology:

  • Diagnostic and screening mammograms.
  • Preventive services as defined in 42 CFR410.2.
  • Ambulance services.
  • Items, procedures or services that have a CMS OPPS Status Indicator of F, G, H, L or U.
    • F is for corneal tissue acquisition cost, certain CRNA services, and Hepatitis B vaccines.
    • G is for pass-through drugs and biologicals.
    • H is for pass-through devices.
    • L is for influenza and pneumococcal pneumonia vaccines.
    • U is for brachytherapy sources.

Steps to Model J1 Reimbursement Using EGID Approach

  • Determine if the claim has a unit or units billed with a CPT code with CMS J1 status indicator. If it does go to the next step; otherwise, the claim will be reimbursed under the standard EGID hospital outpatient payment methodology.
  • Determine if the claim has multiple units of J1 procedure or procedures. If there is only one unit billed with one J1 CPT code, then the claim is a single procedure claim. The fee on the EGID hospital outpatient fee schedule will be the J1 reimbursement. All other services will be packaged and not paid separately unless the item is listed under B above. If the items are separately payable, then the EGID Hospital Outpatient Fee Schedule is referenced.
  • If the claim has multiple J1 units or J1 CPTs, then determine which CPT code has the highest CMS ranking. Use the CMS OPPS Addendum J schedule to determine the CPT ranking or the attachment. The lowest numerically ranked CPT code is defined as the primary CPT code for the claim. If there is not a complexity adjustment, the EGID Hospital Outpatient Fee Schedule will be the J1 reimbursement. All other services or procedures will be bundled and not reimbursed separately even if there is a separate fee assigned on the EGID Hospital Outpatient Fee Schedule unless it is a carve out item mentioned in B above.
  • Determine if the claim should have a complexity adjustment. Generally, CMS established the procedure oriented APCs with different levels of groups of surgeries. For example, APCs 5191-5194 are for endovascular procedures and there is an APC for each of the four levels of complexity. Certain combinations of procedures will receive a complexity adjustment to the next highest APC within the same family of procedures. The combinations of CPT codes and the next highest APC assigned are included in the CMS Addendum J or the attachment.
    • Use the table name CMS Complexity Adj APC Lookup to determine if the primary CPT with any of its secondary CPTs (or a second unit of the primary) are in the table and then therefore receive a complexity adjustment (i.e., the next highest level APC assignment).
    • If the CPT combination is included in the CMS Complexity Adj APC Lookup, then lookup the new APC Assignment (i.e., the Complexity Adjustment Assigned APC) in the next table – the excerpt from the CMS Addendum A with the EGID tier fees added to it. The higher payment is the new bundled fee for the multiple procedures on the claim. Note that many claims will not receive a complexity adjustment as it is only for a certain combination of CPT codes.
    • The bundling rules for other procedures and services will apply the same as described in above.


If your patient requires a Step Therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department toll-free at 800-294-5979. TTY users call 711. 

Preventive services are covered services provided for overall health maintenance such as routine health/wellness exams and tests, vaccinations, well-baby care and well-child care.  

HealthChoice covers qualifying preventive care services at 100% of allowable fees for members who meet clinical criteria. When using a HealthChoice network provider, members have no out-of-pocket cost, though there may be exceptions, limitations or clinical criteria to qualify for these services at no cost. Additionally, if services received during a preventive care visit are for something other than qualifying preventive care, the member will be responsible for the out-of-pocket cost. 

In addition to Affordable Care Act specific requirements, HealthChoice follows the recommendations of the United States Preventive Services Task Force and the American Academy of Pediatrics Bright Futures for the basis of coverage and criteria. 

Providers are encouraged to review the HealthChoice Preventive Services list for any updates, code changes or the addition/deletion of previously listed codes.  

For more details on qualifying preventive care services, visit the HealthChoice Preventive Services webpage or contact Customer Care at toll-free 800-323-4314. TTY users call 711. 


Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice approves the medication for coverage at the appropriate tier.

Providers who request prior authorization must follow this process:

  1. The provider’s office must call the pharmacy benefit manager (PBM). Please have the member ID number, medication name and fax number ready.
  2. The PBM will do one of two things:
    1. Fax a prior authorization form to the provider’s office. The provider must complete this form.
    2. May be able to take the required information verbally over the phone. The representative will ask the necessary questions and record the answers given.
  3. Once their review is complete, the PBM sends notification of the review results to the member and the provider.
  4. If the medication is approved for coverage, the PBM loads the approval into their system within 24 to 48 hours. Written notification of the approval is faxed to the provider and sent to the member within 24 to 48 hours. If the prior authorization is not approved, written notification is faxed to the provider and sent to the member within 24 to 48 hours, along with information for appealing the denial.

For additional information about the HealthChoice pharmacy benefits, reference the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan Handbook or visit the pharmacy benefits information page.


The terms of the HealthChoice contract require that network providers make reasonable efforts to refer their covered patients to other network providers for medically necessary services that they cannot provide or choose not to provide. This includes hospitals, medical supply companies, specialists, laboratories, etc.

Failure to refer to network providers will result in a review pursuant to the credentialing plan.

For additional information, please contact network management.


The medical and dental claims administrator contracts with McAfee & Taft for subrogation recovery services. Subrogation is a plan’s right to seek reimbursement for an accident or injury caused by a third party such as a motor vehicle accident or a slip and fall.

When a claim denies for subrogation, the claims administrator sends the member a notification to contact McAfee & Taft, who then sends the member a letter and questionnaire requesting details about the medical services provided. The member may also complete the questionnaire online at Upon completion, the member is provided a confirmation number for their records. 

If the member does not provide the requested information to McAfee & Taft, the claim will be reprocessed accordingly as member responsibility.


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 interactive 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 only require the use of POS 02. Modifiers are not required. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance.
  • HealthChoice will acknowledge and pay telehealth claims according to the CPT, HCPCS and outpatient fee schedules.
  • HealthChoice excludes telepharmacy networks that use pharmacists to provide services.

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


In the case of a transfer, the transfer allowable fee for the transferring facility is calculated as follows:

Transfer allowable fee = (MS-DRG allowable fee/geometric mean length of stay) x (length of stay + 1 day).

The total transfer allowable fee paid to the transferring facility will be capped at the amount of the MS-DRG allowable fee for a non-transfer case. EGID will allow payment to the receiving facility if it is also the final discharging facility, at the MS-DRG allowable fee as if it were an original admission.

Discharge code Description Discharge procedure
01 Discharged to home or self-care (routine discharged) when beneficiary receives clinically related care that begins within three days after the hospital stay. The discharging hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
02 Discharged/transferred to a short-term general hospital for inpatient care. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
03 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care. The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
05 Discharged/transferred to a designated cancer center or children’s hospital. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
43 Discharged/transferred to a federal care facility. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
62 Discharged/transferred to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part until of a hospital rehabilitation distinct part (DP) units located in an acute care hospital or a CAH.  The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
63 Discharged/transferred to a Medicare certified long-term care hospital (LTCH). The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital. The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
66 Discharged/transferred to a critical access hospital (CAH). Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.


When services are rendered in place of service 20 Urgent Care Facility: location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention, the copay is $30 whether the patient is being seen by a primary care physician or specialist. This applies to the HealthChoice High and High Alternative Plans. High Deductible Health Plan members must first meet their deductible before the copay applies.  


Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits.

CDC-recommended vaccinations, such as for shingles, are covered at 100% when using a network pharmacy. These can also be covered under the health benefit if provided by a recognized network health provider, such as a physician or health department.

Vaccine administration fees are also covered at 100% if the services are provided by a network provider. 

When using a non-network provider, members and dependents are subject to non-network benefits and can be balance billed for amounts above the allowable fees

  • Only network physicians or network providers can provide these services under the medical benefit.
  • Mid-level practitioners such as physician assistants and nurse practitioners practicing at a freestanding ambulatory care clinic located at a pharmacy may not be network.
  • Non-network pharmacists are not recognized and are not covered under the medical benefit.

Covered vaccinations include: 

  • Anthrax.
  • Flu.
  • Haemophilus Influenzae.
  • Hepatitis A.
  • Hepatitis B.
  • Human Papillomavirus.
  • Influenza A.
  • Influenza HD.
  • Japanese Encephalitis.
  • Measles.
  • Meningococcal.
  • Mumps.
  • Pneumococcal.
  • Poliomyelitis.
  • Rabies, Human Diploid.
  • Rabies, PF Chick-EMB Cell.
  • Rotavirus.
  • Rubella.
  • Shingrix (Shingles).
  • Smallpox (Vaccinia) Vaccine.
  • Tetanus Booster.
  • Tetanus, Diphtheria, Pertussis.
  • Typhoid.
  • Varicella.
  • Yellow Fever.
  • Zoster (Shingles).

This list is not all-inclusive. 


While a procedure code may be listed on the fee schedule, all codes are subject to plan policies and provisions, including clinical editing and medical necessity guidelines. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

Venipuncture (36415) is not covered separately when lab work has also been performed and billed by the provider. For lab tests requiring routine venipuncture and subsequently sent to an outside lab, the physician office can bill either the venipuncture service or the handling charge, but not both. These services may be denied as incidental, or included in a primary service when billed in conjunction with another service. 

If further clarification is needed, please contact the claims administrator toll-free 800-323-4314.

A corrective lens can be covered only one time following cataract surgery. This lens should relate to the eye on which the surgery was performed. Frames are not a covered medical benefit.  

Contact lenses are covered only for the diagnosis of keratoconus, an uncommon condition of the eye surface. 

If you have questions, please contact the medical claims administrator. Refer to Contact Information


The wig/scalp prostheses benefit is as follows: 

  • One wig or scalp prostheses per calendar year is covered for members who experience hair loss due to radiation or chemotherapy treatment resulting from a covered medical condition.
  • These must be obtained from a licensed cosmetologist or durable medical equipment provider.
  • For pre-Medicare plans, coverage is subject to calendar year deductible and coinsurance.
  • For Medicare supplement plans, coverage is not subject to calendar year deductible or coinsurance.
  • The wigs and scalp prostheses benefit will be paid per the HealthChoice fee schedule.

For questions about this benefit, call the medical claims administrator toll-free at 800-323-4314. TTY users call 711. 


Last Modified on Feb 27, 2023
Back to Top