TPA Implementation

HealthChoice is adding an advanced claim review (ACR). This program selects certain claims for additional coding review.

Reviews are performed by experts, including some specialty board certified physicians, registered nurses and certified coders. Medical records and/or itemized bills will be required for review.

If claims with billing and/or coding errors are identified, they will be processed to reflect the appropriate payment. Claims are reviewed pre-payment or post-payment.

What changes could you experience for claim editing starting Jan.1, 2023?

1. Certain claims may deny for medical records if not already received from the provider or facility.
2. If error(s) are identified, claims may partially or fully deny as:       

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

For HealthChoice claims with dates of service prior to Jan. 1, 2023, ACR will not apply.

For questions about the HealthChoice ACR implementation, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

When certification is not initiated and approved within the time frames described below, a 10% penalty is applied, if approved retrospectively. The member is not responsible for this penalty.

Certification is required within three business days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures. Certification is required within one day following emergency/urgent services.

Additional information about certifications is on this site.

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

For dates of services after Jan. 1, 2023, HealthChoice is changing the psychiatric office visit copay from a specialist copay of $50 to a primary care office visit copay of $30.

The following specialties are subject to the primary care office visit copay of $30.

• General practice.
• Internal medicine.
• Obstetrics/gynecology.
• Pediatric medicine.
• Physician assistant.
• Nurse practitioner.
• Psychiatry.
• Geriatrics.
• Preventive medicine.
• Urgent care.
• Rural health clinics.
• Federally qualified health centers.
• Military facilities.
• VA facilities.
• Indian health facilities.

All other specialties are subject to the specialist office visit copay which remains $50.

For questions about eligibility and benefits, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Beginning Jan. 1, 2023, HealthChoice will use Credit Balance from Optum to provide on-site and remote-location resources to help providers research and resolve unsolicited and solicited overpaid claims.

What is credit balance resolution?

• This program audits credit balances and overpayments found and documented on provider ledgers.
• Optum verifies the members’ claims administered by UMR and notifies the provider of refund requests.
• Optum verifies the credit balance or overpayment amount and completes the recovery.
• Credit balance and overpayment recoveries made by Optum are sent to UMR monthly for crediting in the UMR claim payment system, and payment reimbursement is sent to HealthChoice.

For questions about credit balance resolution, call Optum at 615-503-1000, option 5.

The Department of Corrections (DOC) transitioned from HealthSCOPE benefits as its third-party administrator to UMR. 

For dates of service on or after Jan. 1, 2023, DOC providers need to: 

• Bill with group number 76415170.
• Update the inmate ID to utilize a prefix of 3650 + the DOC inmate ID number.
• Enter the prefix 3650 + DOC inmate ID number when making a DOC inquiry using the IVR system or provider portal.

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

UMR will be the new claims processor for HealthChoice, DOC and DRS claims with dates of service beginning Jan. 1, 2023. The payment disbursement vendor will also change from ECHO Health to Optum. HealthSCOPE Benefits will continue to process claims received in 2023 with a 2022 date of service, and ECHO Health will continue to process those payments.

Providers

If you are currently enrolled under UMR payer ID 39026 with OptumInsight for 835 electronic remittance advices or Optum Pay for ERAs, you do not need to register.

If you are not currently enrolled for remittances under UMR payer ID 39026, you can enroll at any time. UMR will automatically transfer your enrollment from payer ID 39026 to HealthChoice payer ID 71064 and DOC\DRS payer ID 71065 effective Jan. 1, 2023.

To enroll for ERAs via OptumInsight, call 866-367-9778 and choose Option 1.

• If you contact OptumInsight prior to Jan. 1, 2023, ask to enroll for payer ID 39026.
• If you contact OptumInsight after Jan. 1, 2023, ask to enroll for payer IDs 71064 and 71065.

You can also enroll for Optum Pay ERAs. With this option, you can view and download remittance information. HealthChoice encourages you to enroll or confirm you are currently enrolled by calling 877-620-6194.

Clearinghouse connections

You can also enroll to receive ERAs through your current clearinghouse.

• If you request to enroll prior to Jan. 1, 2023, ask your clearinghouse to enroll you for payer ID 39026.
• If you request to enroll after Jan. 1, 2023, ask your clearinghouse to enroll you for payer IDs 71064 and 71065.

What happens if I do not enroll for ERAs by Jan. 1, 2023?

If you do not enroll for 835 remittances or ERAs, you will need to view claim information on the HealthChoice provider portal or request copies of remittances from Customer Care at 800-323-4314. If you have any questions, please call Customer Care at 800-323-4314.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR.

The HealthChoice code review vendor will also change from HealthSCOPE/McKesson to UMR/Clinical Editing System (CES).

The UMR Code Review team reviews all newly implemented codes. CES applies the editing on claims received for processing.

What changes might you experience for claim editing, beginning Jan. 1, 2023?

1. Claims with a code-to-code relationship present, billing of modifier 59 or equivalent X modifiers will not automatically override the claim editing. UMR will require medical records for review.
2. Claims with a code-to-code relationship present between an E & M code and procedure code, billing of a modifier 25 will not automatically override the claim editing. UMR will require medical records for review.
3. HealthChoice facility claims will now receive code editing.

For HealthChoice claims with dates of service before Jan. 1, 2023, HealthSCOPE/McKesson will continue to apply editing on claims.

For questions about the claim submission process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR.

Providers can continue to access the Availity web portal for direct data entry of all claims in 2022 and prior dates of service. Providers are urged to submit claims for adjudication as soon as possible once services are rendered. This will ensure that claims may be timely adjudicated by HealthSCOPE during the designated run-out period.

What changes could you experience for data entry of claims and additional information, beginning Jan. 1, 2023?

The HealthChoice direct data entry of claims vendor will change to the UMR submissions vendor PCH for claims with dates of service on or after Jan. 1, 2023.

Steps to register

To register, visit the PCH home page:

1. Select My Account from the top menu bar.
2. Choose Sign up from the drop-down menu.
3. Complete the form (left) and select Submit.

What type of correspondence can be submitted through the PCH provider portal?

• Single-submission claims.
• Supporting dental documentation.
• Itemized medical statements and records.
• This application does not include submission for certifications.

Where can I go to check the status of submitted documents?

Providers can check the status of submitted documents in the Reports tab once you have access and log into PCH.

For questions about the direct data entry process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.

Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR. Providers will not need to make any changes to electronic data interchange (EDI) payer IDs in their system.

The payer ID or EDI number is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility, benefits and submit claims.

Continue to use the same HealthChoice, DOC and DRS EDI payer IDs used today after Jan. 1, 2023:

• 71064 HealthChoice.
• 71065 DOC and DRS.

Optum – UMR’s clearinghouse for claim files – works with several clearinghouses to receive claims.

HealthChoice members will receive new ID cards for the 2023 plan year that will reflect the payer IDs listed above. The new ID cards will also have these UMR-assigned group numbers:

• 76415077 HealthChoice (member IDs will remain the same).
• 76415170 Oklahoma DOC (member IDs will continue to be the inmate ID).
• 76415171 Oklahoma DRS (UMR will issue new member IDs).

For questions regarding this update, call Customer Care at 800-323-4314. TTY users call 711.

UMR will be the new claims processor for HealthChoice, DOC and DRS processing claims with dates of service beginning Jan. 1, 2023. As a provider, you will be able to receive direct deposit of claim payments processed by UMR.

HealthChoice encourages you to enroll now with Optum Pay or by calling 877-620-6194.

You will need the following information to complete your enrollment online:

• The payment method for your organization.
  • Direct deposit (ACH).
  • Virtual card payments (VCP).
• Organization name, mailing information and tax identification number (TIN).
• Contact information for your designated Optum Pay contacts.
• Banking information for the ACH option.
• Your organization's W-9 form.
• A voided check or bank letter for each account where payments will be deposited for the ACH option.
• There will be an option to enroll for virtual card payments.
  • This option is currently not available for payments made by HealthChoice.
  • If you enroll for virtual cards in error, you will receive checks.
  • Virtual cards will be available as a payment option in 2023.

What happens if I do not enroll?

You will receive a paper check for dates of service after Jan. 1, 2023, if you are not enrolled in Optum Pay.

Benefits of electronic payments

• Payments arrive sooner than checks.
• No lost payments.
• Often see less administrative costs with receiving electronic payments.
• Payments viewable through the Optum Pay web portal.
  • Free basic service or paid premium service available with more robust reporting options.
  • Remittance advices and 835 transaction data is available.

For questions about EFT enrollment, call the Customer Care team at toll-free 800-323-4314. TTY Users call 711.

Examples of the overpayment notification and the corresponding remit advice notification and recoupment can be found here.

For dates of service on or after Jan. 1, 2023, EGID will apply the lesser of billed charges or the HealthChoice allowable fee across all payments.

By way of this notice, we are notifying providers that all contract language has been updated to our most current versions, is available on the HealthChoice Provider website, and includes the lesser of language which will apply to all claims for DOS on or after Jan. 1, 2023.

For questions, call Network Management at 405-717-8790 or toll-free 800-543-6044.

As we transition to UMR on Jan. 1, 2023, we will be moving from VARIS for inpatient post-payment review to UMR.

Providing medical records to VARIS timely will be critical during this change. All medical records will need to be sent directly to the address indicated on the request. There could be a possible retraction of the full payment if the records are not received on time.

VARIS will review the medical records and provide a letter with rationale for any potential change to the DRG. The facility will have 60 days to sign the acknowledgement letter and include the overpayment. If you do not agree with the DRG change, please send a letter of appeal and any additional supporting documentation to VARIS. All contract provisions apply.

VARIS will work directly with you regarding any questions from your facility.