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.

4109

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).

4071

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.

4107

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)

4070

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.

4066

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.

4477

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: 

4167

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.

4069

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.

3747

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 https://gateway.sib.ok.gov/feeschedule/Login.aspx.  

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.

4075

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.

4116

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.  

4144

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.

4095

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.
  • 80300 DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES.
  • G0477 DRUG TEST PRESUMP; CPBL BEING READ DC OPT OBV ONLY.
  • G0478 DRUG TEST PRESUMP; READ BY INSTRUM-AST DC OPT OBV.
  • G0479 DRUG TEST PRESUMP; INSTRUMENTED CHEMISTRY ANLYZER.
• 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.

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

4084

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:

4085

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.

4437

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  healthchoice@service.govdelivery.com. To make sure you do not miss the newsletter or other communications, add this new email address to your safe senders list. 

4082

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. 

4088

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

Introduction 

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.

3839

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. 

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.

4089

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.

4090

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 www.mtsubrogation.com. 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.

4124

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. 

4140

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.

 4091 

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.  

4093

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. 

4125

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. 

4094

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. 

4146