2009 Global Messages

Posted
Date

Subject

Message

Title: School Based Billing Rate Changes

Run Date: 04/05/2010 – 04/30/2010

Pv Types: 12 – School Corporations 120 – School Corporations

Effective 4/1/2010 School-Based billing rates have changed.

Review the update fee-schedule rates on the OHCA Web site on our School-Based page.

Title: Follow-up to Provider Letter 2009-48

Run Date: 12/29/2009 – 02/13/2010

PV Type: 27 – Dentist 271 – General Dentistry

Please be advised that the effective date of the change in rates noted in Provider Letter 2009-48 is January 1, 2010.

Title: Compressor Driven Nebulizers E0570 & E0571

Run Date: 12/29/2009 – 02/13/2010

PV Type:  250 – DME/Med Supply Dealer

Message:

Due to the budget crisis, Provider Letter 2009-41 is retracted and replaced with a purchase option ONLY for Compressor Driven Nebulizers: Codes E0570 Compressor Driven Nebulizer and E0571 Battery Operated Aerosol Compressor at a rate of $120.00.  THERE IS NO RENTAL OPTION. 

TITLE: DME – MAX Units Limits

Run Dates: 12/07/2009 – 03/31/2010

PV Types: 250 – DME/Medical Supply Dealers

Message:

Many of the Oklahoma Health Care Authority policies have supplies or accessories with usual maximum quantities and frequency limits. Suppliers are not expected to provide these amounts routinely, nor are beneficiaries required to accept supplies or accessories at this frequency or in quantities that exceed the amount they typically use. Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Reordering of supplies and accessories is based upon actual member usage. Suppliers should stay attuned to atypical utilization patterns on behalf of their clients and verify with the ordering physicians that the atypical utilization is, in fact, warranted.

A member or their caregiver must specifically request refills of supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined basis, even if the member has "authorized" this in advance. As referenced in the Program Integrity Manual (Internet-Only Manual, CMS Pub. 100-8, Chapter 4.26.1) "Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product."

Title: DME Capped Rental Fee Adjustments

Run Date: 12/04/2009 – 03/31/2010 

PV Type:  250 – DME/Medical Supply Dealer

Message:

Please be advised that effective January 1, 2010 OHCA will implement a change to Capped Rental fees.

The fee schedule will reflect the Medicare fee schedule taking into consideration the Medicare method of paying for the first 3 months at the full allowable and months 4-13 at 75% of the full allowable.

OHCA will pay Capped Rental items spread over the 13 month capped period by dividing the calculated Medicare allowable by 13 to arrive at the fee schedule amount.

You can access the affected HCPCS codes under www.okhca.org – DME webpage.  The secure website does not list LL codes; however an updated TXIX fee schedule will be published for your use in January 2010.

Title: TENS UNIT Prior Authorization / TENS HCPCS Codes E0720, E730, E731

Run Date: 12/01/2009 – 01/15/2010

PV Types: 250 – DME/Medical Supply Dealer

Message:

Please be advised that effective January 1, 2010 OHCA will implement a change to require Prior Authorization for TENS Units and Related garments. 

E0720 – Trancutaneous electric nerve stimulation (TENS) device, 2 lead, localized stimulation

E0730 - Trancutaneous electric nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation

E0731 – Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient’s skin by layers of fabric
            
A physician signed copy of the HCA-39 – CMN for TENS must be submitted along with evidence that a 30 day trial has been tried by the physician prior to prescribing the TENS unit. See Question # 5. 

Electrodes – HCPCS - A4556 are covered up to 4 per month with evidence of medical necessity on file in case of an audit.

Title:Revisions to FORM CH-16, Psychosocial Assessment

Run Date:11/16/2009 -12/31/2009

PV:   91 – OB Nurse Practitioner, 328 – OB/GYN

Message:
The revised Form CH-16, Psychosocial Assessment, is now available on the OHCA Web site.

TITLE:  Anethesia Claims with QX Modifier

Run Date: 11/23/2009 – 01/07/2010

PV Types: SPC – 101 Anesthesiology Assistant

Message:
For appropriate billing please submit all claims for anesthesia with modifier QX. This will insure proper payment. Improper billing will result in post payment review and recoupment of funds.

For questions, please call 1-877-823-4529 option #2 to speak with a Provider Representative. 

Thanks.

Title: Reminder: Claim Form Submissions

Run Date: 11/17/2009 – 12/31/2009

PV Types: All

Message:

Please submit original red-and-white claim forms for both initial and resubmission of your claims.

Reproductions of originals do not scan properly and therefore payment may be delayed.

Thank you.

Title: OB Providers and Seasonal Flu Shots

Run Date:  11/06/2009 – 12/21/2009

PV Spc Types: 091 - OB Nurse Practitioner 328 – OB/GYN

Message:

Effective 10/1/2009,OB/GYN Providers can bill for the Seasonal Flu Shots for SoonerCare members, using  CPT Codes 90658 and 90471. It is no longer necessary to obtain a referral to bill for these immunizations.

PLEASE NOTE:  The Seasonal Flu vaccine is available to only SoonerCare Program members. It is not a covered benefit for the Soon-to-be-Sooner Program members.

Thank you.

Title:  Reminder: Modifiers 25 & 59

Run Date: 11/06/2009 – 12/21/2009

PV Types: All

Message:

Effective October 1, 2005, claims billed with modifier 25 will be denied unless sufficient documentation is attached to the claim.  Claims utilizing modifier 25 must include documentation (office notes) to justify payment for a significant and separately identifiable evaluation service by the same physician on the same day of a minor (global) surgery/procedure.

Effective January 15, 2007, claims with modifier 59 will be reviewed.  These claims must have sufficient documentation (Op reports when applicable) to justify payment for a distinct and separate procedural service.  Claims submitted without sufficient documentation will be denied.

Please reference Dear Provider Letter OHCA 2005-30 for further explanation.

Thank you.

Title:  Reminder: 1500 Claim form Submissions

Run Date: 11/06/2009 – 12/21/2009

PV Types: All

Message:

Please submit original red-and-white 1500 Claim Forms for both initial and resubmission of your claims.

Reproductions of originals do not scan properly and therefore payment may be further delayed.

Thank you.

Title:  Unit of Measure Changed – HCPCS A4230

Run Dates: 11/06/2009 – 12/31/2009

PV Types: 250 – DME/Medical Supply Dealer

Please be advised the HCPCS code A4230 – Infusion set for external insulin pump, nonneedle cannula type unit of measure has been changed for dates of service on or after November 1, 2009 from boxes to each.

Max units of 15 will be allowed with medical necessity at a rate of $ 11.00 each after November 1, 2009.

Please make note of the change.

Title: Speech Therapy

Run Date: 11/02/209 – 12/17/2009

Pv Type:  173 – Speech/Hearing Therapist, 182 – Speech/Hearing Clinic

Message:

This message is to provide clarification on changes you will observe on the website relating to the maximum number of units displayed effective 11/1/2009. For procedure codes 92507 and 92508 the maximum number of units will be 260 per year.  The maximum number of units allowed must be prior authorized. There are system parameters that control the number of units allowed per year based on what is prior authorized. This does not change the daily allowed unit of one per day.

Effective 12/1/2009, procedure codes 92630, 92633, 97532, and 97533 will require prior authorization. For questions, please contact 1-800-522-0114 (toll free) or 405-522-6205 (local); option 6, then option 3.

Title: PA Required for CPM

Run Dates: 10/19/2009 – 12/05/2009

PV Types: 250-DME/Medical Supply Dealer

Please be advised that effective August 1, 2009 OHCA will require Prior Authorization for E0935 – Continuous Passive Motion exercise device for use on knee only - CPM

OHCA covers a CPM device as medically necessary for up to 21 days in a patient in an early phase of rehabilitation when either of the following criteria is met:

• As an adjunct to active physical therapy following total knee replacement, including revision or revision of a worn component
• As an adjunct to active physical therapy following anterior or posterior cruciate ligament (ACL, PCL) reconstruction
• As an adjunct to conventional physical therapy during non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, treatment of osteochondritis dissecans, and repair of tibial plateau fractures 
              
We regret the delay in notifying DME providers and will assist any provider for CPM products issued during the period      of August 1 to October 19, 2009 to obtain a PA if qualifying medical necessity is provided to the MAU unit.

2009 Soonercare Fall Training Workshops/Tulsa Registration Closing October 20th

PV Types: All

Run Dates:

Registration for the Tulsa location will close Tuesday, October 20, 2009.

Class information and online registration can be found on our Training page..  Please complete your registration today to reserve your spot.

CONSTRUCTION UPDATE - Construction near OSU-Tulsa has closed both Greenwood Avenue and Cincinnati Avenue.  Additional information on the construction detours can be found at (Expired Link).

Title: Correction:  Form ADA-2006

Run Date: 10/08/2009 - 11/23/2009

PV Types: 27 – Dentist, 86 – Dental Clinic, 271 – General Dentistry Practitioner, 274 – Pediatric Dentist

Message:
If the ADA 2006 Claim Form is being used for prior authorization, it is not necessary for the dentist to sign the form per CDT 2009-2010.

We apologize for any inconvenience.

Title: OHCA Dental Services Office Relocation

Run Date: 10/06/2009 – 10/15/2009

PV Types: 27 – Dentist, 86 – Dental Clinic, 271 – General Dentistry Practitioner, 274 – Pediatric Dentist

Message:
On October 13, 2009 the OHCA Dental Services Office will be physically relocating and may be temporarily unavailable at times during that transition.

Thank you.

Title: DDSD Provider Contracts

Run Date: 10/05/2009 – 11/20/2009

PV Types: 48 – DDSD – NFM, 49 – DDSD – Supportive Living, 218 – DDSD – ICFMR Waiver, 480 – DDSD – NFM, 493 – DDSD – Supportive Living

Message:
If you are a DDSD provider wanting to renew your contract please follow the instructions you received on your renewal notice. Our online enrollment is not currently set up for DDSD providers. If you renew online your renewal will not be processed.

2009 Soonercare Fall Training Workshops – Oklahoma City, OK

PV Types: All

Run Dates:

OHCA and HP  Enterprise Services will be conducting the Fall 2009 SoonerCare Provider Training Workshops which will include several specialty sessions for specific provider types in Oklahoma City on October 13 and October 14.
Registration for the Oklahoma City location will close Tuesday, October 6, 2009.
Class information and online registration for all locations can be found on the OHCA website on our Training page. Please complete your registration today to reserve your spot. We look forward to seeing you there!

Title: HCA-46 Dental Change of Provider Request Form

Run Date: 09/25/2009 - 11/10/2009

PV Type: 27 – Dentist, 86 – Dental Clinic

Message:
The HCA-46 DENTAL CHANGE OF PROVIDER REQUEST FORM is now available on the OHCA Web site. 

Thank you.

Title: Submitting Crossover Claims via Secure Site

Run Date: 09/14/2009 – 11/01/2009

Pv Types: All

Message:

OHCA would like to announce that providers can now submit your Medicare crossover claims via the Secure site.  The HCA-28 is not necessary for internet crossovers.  If the crossover requires an attachment to process correctly, follow your normal attachment procedures for these claims.

To file a Medicare crossover, select from the claim type drop down, Professional Crossover, Inpatient Crossover or Outpatient Crossover. 

We hope this new capability eases your burden of filing paper Medicare cross over claims. However, keep in mind that claims should process from Medicare to OHCA without intervention. 

If your claims persistently do not cross to OHCA, please contact OHCA Provider Services, 1-877-823-4529 option #2, to determine if there is a problem with the provider file.

MSSG: 2009 Soonercare Fall Training Workshops – Durant, OK

PV Types: All

Run Dates: 09/14/2009 – 09/23/2009

OHCA and EDS, an HP company, will be conducting the Fall 2009 SoonerCare Provider Training Workshops which will include several specialty sessions for specific provider types.

Registration for the Durant location will close Wednesday, September 16, 2009.

Class information and online registration for all locations can be found on the OHCA website on our Training page. Please complete your registration today to reserve your spot. We look forward to seeing you there!

Title: Current Denial on Admission (POA) Indicators

To: (Acute Care & Critical Access Inpatient Hospital Facilities)
01 – Hospitals
010 – Acute Care
014 – Critical Care

Run Date: 09/03/2009 – 10/18/2009
  
Message:

At this time, not all of the diagnosis codes which should have been exempt from the POA processing were loaded into the system correctly. This has caused some claims to deny inappropriately.
We expect the system to be corrected by the end of the week (9/4/09). Please resubmit any claims that denied for this reason after 9/8/09.
We apologize for the inconvenience this has caused.

Beginning December 1, 2009, all claims submitted via batch file 837P or 837I must contain the contract source for each service line on each claim.  

This contract source should be sent in 837 files as follows:

Loop Segment          

2400 HCP  

Example: HCP*10*50.00**00AA~

Information will be forthcoming on how this data will be returned on the electronic remittance advice.

For additional information please contact your software vendor or clearinghouse.  You may also download an updated Oklahoma SoonerCare HIPAA companion document on our EDI page.

Title: 2009 Fall Workshop Registration

Run Date: 09/01/2009 – 10/26/2009

Pv Types: All  

***Fall Workshop Registration is now available!****
For details on class descriptions and locations, please visit: (Expired Link)

Title: New PA Update for Hospital Beds: E0255, E0260

Run Date: 08/20/2009 – 11/01/2009

PV Type: 250 – DME/Medical Supply Dealer

Message:

Effective with initial dates of service after September 1, 2009, the Prior Authorization requirements for Hospital Beds have been updated.  Rental for codes E0255 and E0260 will not require prior authorization for reimbursement for the first month of billing.

HCPCS Codes E0255, Hospital Bed variable height, hi-lo, with any type side rails, with mattress and E0260, Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress will require prior authorization before billing the second month of continuous rental. 
The OHCA CMN HCA-30 must be submitted with medical necessity documentation to support the prior authorization request submitted on the HCA 12A.

Title: Osteoporosis Meds

Run Date: 08/14/2009 – 09/30/2009

PV Type: 24, 240 – Pharmacy, 31 - Physicians

Message:
Step therapy requirements for Osteoporosis Medications take effect August 19, 2009.  For Pharmacy prior authorization, use form Pharm-4.  For Outpatient/Physician prior authorization, use form Pharm-18.  For PA criteria, please see our Pharmacy PA page.

Title: Correction to: Audiology Pricing Changes

Effective 05/15/2009

Run Date: 08/14/2009 – 09/30/2009

PV Type: 20 – Audiologist, 22 – Hearing Aid Dealers, 173 – Speech/Hearing Therapists, 220 – Hearing Aid Dealers

MESSAGE:
An amendment is being made to this Banner #324 Message, the corresponding Global Message, and the corresponding Dear Provider Letter #2009-21 Re: Audiology Pricing Effective May 15, 2009.
CHANGE: Remove V5244. Add V5254.
Codes affected should now correctly read:  V5254, V5255, V5256, V5257, V5258, V5259, V5260, and V5261.

Title: Update to Banner #352 - 270/271 Submitters and Receivers-Breast & Cervical Cancer Screening Dates  - Cancellation Notice

Run Dates: 08/11/2009 – 09/25/2009

PV Types: All

Please disregard Banner Message #352/ Global Message RE: 270/271 Submitters & Receivers – Breast and Cervical Cancer Screening Dates.  This message is currently null & void and has been removed from the system. Future updates will be posted as applicable.

We apologize for any confusion or inconvenience. Thank you.

Title: Individual Physician Contracts

Run Date:  08/07/2009 – 10/01/2009

PV Types: 31 – Physicians

Individual Physician contracts expire September 30, 2009. Please visit the OHCA website to download the contract and send to Provider Enrollment for processing.

Title: 270/271 Submitters and Receivers – Breast & Cervical Cancer Screening Dates

Run Date: 08/03/2009 – 12/31/2009

PV Types: All

Effective 08/22/2009 OHCA will begin returning Breast and Cervical Cancer screening dates, and last Emergency Room visits in the 271 Eligibility Response transaction.  This information will be in Loop 2110C.
EB01 = W
EB02 = IND
EB03 = BM, AN, or 86
DTP01 = 472
DTP02 = D8
DTP03 = Will contain date of service for applicable service.

Example:
EB*W*IND*AN~
DTP*472*D8*20080914~

For EB03 values, BM will signify a breast screening service, AN will signify a cervical screening service, and 86 will signify an Emergency Room visit.

Please make the necessary coding changes to accept this information.  For questions please contact the EDI Help Desk at 405-416-6801.

Title: 270/271 Submitters and Receivers – LOC Information Added

Run Date: 08/03/2009 – 12/31/2009

PV Types: All

Message:

Effective August 22, 2009, OHCA will begin returning Level of Care information in the 271 Eligibility Response transactions.  This information will be in Loop 2110C.
EB01 = X
EB02 = IND
EB03 = 54
EB05 = Will contain level of care description
DTP01 = 472
DTP02 = RD8
DTP03 = Will contain date range for level of care information.

Example:
EB*X*IND*54**Assisted Living~
DTP*472*RD8*20090430-22991231~

Please make the necessary coding changes to accept this information.  For questions please contact the EDI Help Desk at 405-416-6801.

Title: CPT 63650/HCPCS Device Code L8680

Run Date: 08/06/2009 – 09/21/2009

PV Types: All

Message:

Effective 08/15/2009, OHCA will no longer reimburse for CPT code 63650: Percutaneous implantation of neurostimulator electrode array, epidural; or the associated HCPCS device code L8680: Implantable neurostimulator electrode in the physician’s office setting. 

On January 1, 2009, OHCA adopted the CMS OPPS payment system in which the procedure and associated device are assigned to a “device driven procedure” table meaning the procedure cannot be billed without the device. The HCPCS device codes assigned for the procedure (C1778/C18897) are facility only codes to be used with inpatient and outpatient claims. All coverage for L code device was removed when this change was implemented. 

Title: ER Payment Logic re MRIs

Run Dates: 08/04/2009 – 09/19/2009

PV Types: Hospitals – 01 Spcs:  010 – Acute Care, 014 – Critical Access

Message:

The unbundling of facility emergency department (ED) visits January 1st, 2009 affected our ability to process MRIs without a PA in the ED setting.  A change order is being worked to correct this problem; however until it is in place you will need to file a paper claim for the MRI.

If you have a claim for a date of service on or after January 1st 2009 with a paid ED visit and an MRI that has denied for a PA, please resubmit the claim to Provider Services at PO Box 18506, OKC, OK 73154 along with the required HCA-17.  We will special process the claim.

We apologize for the inconvenience.

Title: Dental Provider Letter 2009-33 - Survey Reminder

Run Date: 08/03/2009 – 08/05/2009

PV Type: 27 Dentist, 86 Dental Clinic, 271 General Dentistry Practitioner, 274 Pediatric Dentist

You recently received a letter 2009-33 regarding federal requirements related to the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3.

A survey was included with the letter. Please make sure you return the survey quickly. Please mail the survey back in the enclosed return envelope or you may fax the survey to 405-530-7256.

Thank you if you have already responded to the survey.

OHCA appreciates your continued support of this program.

Title: Blood Lead Testing

Run Dates: 07/30/2009 – 10/30/2009

Provider Types: 31 – Physicians, 88 – Pediatric Clinic, 90 – Pediatric Nurse Practitioner, 81 – Nurse Practitioner Clinic, 100 – Physician Assistant, 345 – General Pediatrician

Did you know?

1. SoonerCare Pays for Blood Lead testing -Procedure Code 83655.

2. Blood lead screening tests (by either finger stick or venipuncture) must be performed between the ages of 9 and 12 months and at 24 months during the regular child health checkup.

3. Federal rules for Medicaid require a blood lead test be performed on any child who has not been previously tested up to age 72 months.

4. A blood lead test equal to or greater than 10 micrograms per deciliter (ug/dL) obtained by capillary specimen (finger stick) must be confirmed using a venous blood sample.

5. All health care providers must notify the Oklahoma Childhood Lead Poison Prevention Program (OCLPPP) of any blood lead level in a child up to 72 months of age equal to or > 10 ug/dL, within 1 week and equal to or >20 ug/dL within 24 hours of having been notified of this results by the testing laboratory according to rules set forth by the Oklahoma State Board of Health (310:512-3-5 Section B-3). The following information shall be provided when reporting: name, date of birth, address, county of residence, etc. Contact number 1-800-766-2223 or 405-271-6617.

6. If you have any questions please call the Child Health Unit at 405-522-7188.

Title: Screening Tools
Run Date: 07/27/2009 – 10/30/2009
Pv Types: 31 – Physicians, 88 – Pediatric Clinic, 90 – Pediatric Nurse Practitioner, 81 – Nurse Practitioner Clinic, 100 – Physician Assistant, 345 – General Pediatrician

Message:

Did You Know?

Evidence-based developmental screening tools (PEDS, ASQ3 and ASQ-SE) are available FREE, through the OSDH/Child Guidance Program, to practices in Oklahoma who serve as PCPs for infants and toddlers.  In addition to receiving the screening tools without charge, a Child Guidance professional will, upon request, assist the practice in using the tools effectively and efficiently and will assist the practice in referring at risk infants, toddlers and young children to appropriate resources.  

To receive the FREE tools contact Amy Chlouber, Infant and Early Childhood Mental Health Coordinator at 888-803-6391 or (405) 271-4477 or email (AmyBC@health.ok.gov).

If you have any other questions about developmental screening in SoonerCare, please call the Child Health line at (405) 522-7188.

Title: Clarification of Provider Letter 2009-28

Run Date: 07/23/2009 – 09/10/2009

PV Types: All

This letter was intended to facilitate your claims payments. It is simply a reminder of our current process. Claims are denied if medical necessity is not documented.

This often occurs when a procedure, which ordinarily does not require prior authorization (PA) and which is rarely done in a facility or under anesthesia, is scheduled at an outpatient facility due to specific patient needs. To avoid claim denial, you may ”submit a PA request to the OHCA medical authorization unit” prior to the procedure.

Please review the letter and call Provider Services if you have any further questions. 

Title: Behavioral Health Diagnostic Codes

Run Date: 07/16/2009 – 09/01/2009

PV Types: All 
  
Message:

Behavioral Health providers need to be aware that 67 of the ICD-9 Behavioral Health diagnostic codes became invalid as of 6/30/2009. This is the result of the newly updated 2009 ICD-9 Code Book (Volumes 1, 2 & 3). The codes can be viewed at: /content/sok-wcm/en/okhcaproviders.aspx?id=406

Most changes involve moving to a 4-digit code as opposed to the previously used 5-digit code. Many of the previously used 5-digit DX codes have simply been modified by removing the 0 at the end, resulting in the new 4-digit code.
EXAMPLE:  Anorexia Nervosa – Previous Code 30710 vs. 2009 Code 3071.

A valid ICD-9 DX code must be used for claims to pay. It is necessary to refer to the 2009 ICD-9 Code Book(s) to insure correct diagnostic coding is submitted.

Claims using invalid codes will deny which will result in delayed claims payments.

Title: Focus on Excellence Letter – Correction

PV Types: 030 – Nursing Facilities

Run Date: 07/07/2009 – 08/24/2009

Please note the following correction to the letter regarding Focus on Excellence dated 06/22/2009. 

CORRECTION:
The letter should read “…points earned for July thru September…”.

Thank you.

Title: Prior Authorization Override Limits Increased for Wound Care Codes

Run Date: 07/06/2009 - 08/23/2009

PV Types: 250 – DME/Medical Supply Dealer

Message:

For dates of service after March 1, 2009, wound care limits have been raised to allow for prior authorization override if medical necessity documentation is provided to support the additional units requested.
For those dates of service from March 1, 2009 thru July 1, 2009, providers will need to send their medical necessity documentation along with HCA-12A for authorization review by regular mail to Oklahoma Health Care Authority, 4545 N Lincoln Blvd. # 124, Oklahoma City, OK  73105 – Attention: Natasha Case – MAU.
For dates of service after 7/1/09, a prior authorization request HCA-12A must be submitted for additional units and sent to EDS, Attention: Prior Authorization, 2401 NW 23rd, Suite 11, Oklahoma City, OK  73107, or faxed to 405.702.9080 or 1.866.574.4991.
See the selected codes affected on the DME Website under – Wound Care Codes Updated 7/1/09.

Title: DME Repair Code E1340 Removed

Run Date: 07/01/2009 – 08/31/2009

PV Types: 250 – DME/Medical Supply Dealer 251 – Assistive Technology Dealer

Message:

The current repair code E1340 will be removed as of August 1, 2009.  It has been replaced by codes K0739 and K0740 (see description below).
OHCA has added two new labor repair codes approved by CMS effective 04/01/2009. Both repair codes listed require Prior Authorization.
K0739: Repair or non-routine service for DME other than oxygen requiring the skill of a technician, labor component, per 15 minutes; and,
K0740: Repair or non-routine service for Oxygen Equipment requiring the skill of a technician, labor component, per 15 minutes.

Title: Revenue Code 51

Run Date: 06/29/2009 -08/13/2009

PV  Spc Types: 081 – RHC, 184 – Hospital Based RHC, 185 – Free Standing RHC

Message:

Currently our system requires you to bill with REVENUE Code 521 in order to receive payments. Our system is also set to suspend claims when any other Revenue code is used. This system structure will not allow you to bill for no-shows.

Please do not bill your no-show appointment(s) until we can work on a system solution.
If you have billed 99499 and received payment, please void these claims.

If claims are not corrected in our system, OHCA will recoup the payment.

Thank you.

Title: Scam Alert

Run Date: 06/22/2009-08/07/2009

PV Types: All

Message:

The Centers for Medicare & Medicaid Services (CMS) has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC).  The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments.  The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.
 
Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request.  If you receive a request for information in the manner described above, please check with your contractor before submitting any information.  Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found at (Expired Link).

Title: The American Recovery and Reinvestment Act of 2009

Run Date: 06/19/2009 – 08/05/2009

PV Types: All

The American Recovery and Reinvestment Act of 2009 (the "Recovery Act") (Pub. L. 111-5) provides for Medicare and Medicaid incentive payments for eligible providers, such as physicians and hospitals, in order to promote the adoption of EHRs.  To receive the incentive payments, providers must demonstrate "meaningful use" of a certified EHR.  HHS expects to issue the proposed rule in late 2009, which will be followed by a comment period.

The Office of the National Coordinator for Health Information Technology (ONC) is seeking comments on this preliminary definition of “meaningful use.”  Comments on the draft description of “meaningful use” are due by 5 pm EST on June 26, 2009, and should be no more than 2,000 words in length.

To view the Meaningful Use Matrix, please use the following link: (Expired Link)

To read the Meaningful Use Preamble, please use the following link: (Expired Link)

Electronic responses to the draft description of “meaningful use” are preferred and should be addressed to: MeaningfulUse@hhs.gov (With the subject line “Meaningful Use”)

Title: MMIS System Maintenance

Run Date: 06/18/2009 – 06/22/2009

PV Type: All

The MMIS system will be down for extended maintenance from 8:00 p.m. June 19, 2009 through 8:00 a.m. June 20, 2009

Title: DME – Prior Authorization Requirement Added effective 07/01/2009

Run Date:  06/15/2009 – 08/01/2009

PV Types:  250-DME/Medical Supply Dealer, 25 – DME/Medical Supply Dealer, 31 – Physicians

Message:

Physician’s orders and medical necessity documentation supporting the need for the equipment must be included with all HCA-12A prior authorization requests.

The following codes will require Prior Authorization by the Medical Authorization Unit, Oklahoma Health Care Authority; effective July 1, 2009.   For code E0675 – Pneumatic compression device, an HCA-33 CMN is required.

E0217 – Water Circulating Heat Pad with Pump - Maximum Allowed: 1 allowed every 5 years

E0675 – Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system) – refer to Policy # 317:30-5-211.10 (b) which states that a CMN is required for pneumatic compression devices (HCA-33 – see www.okhca.org to obtain CMN copy) – Maximum Allowed: 1 allowed every 5 years.

Title: SoonerCare Physician Fee Schedule Updates

Run Date: 06/11/2009 – 07/26/2009

PV Types: All

Message:

This is another reminder that SoonerCare Physician fee schedule updates are effective July 1, 2009. Codes that use RBRVS pricing are based on 100% of Medicare so you may see some changes in reimbursement for services after 7/1/09.

Thank you.

Title: Specialty Providers regarding INSURE OKLAHOMA Members

Run Dates: 06/04/2009 – 07/19/2009

Pv Types: All

Message:

Specialty providers who have SoonerCare contracts are automatically part of the INSURE OKLAHOMA network and do not require a separate contract. Specialty visits do require a referral from the member’s Primary Care Provider.

Primary Care Providers must complete the INSURE OKLAHOMA addendum to provide services to INSURE OKLAHOMA members.

Title: VFC Billing

Run Dates: 06/03/2009 – 07/17/2009 

PV Types: 80 – FQHC 81 – RHC’s

If you have received notice regarding VFC billing that included a claims report, please disregard.

If you have questions please call OHCA Provider Services at 1-877-823-4529, option #2.

Thank you.

Title: Outpatient Claims Processing Fix

Run Dates: 05/27/2009 – 07/10/2009

Pv Types: 01; 010, 012, 014

OHCA was experiencing a system issue in the processing of the flat fee revenue codes. The system fix was completed on May 15th, 2009.  

We will start reprocessing these claims immediately by the mass adjustment process. The adjusted claim’s ICNs will start with a “52” and will begin appearing on your June 3rd remits. Due to the volume of claims involved you will see a large number of adjustments suspended. 

Completion is expected by the end of June.

Title: Update: Code H0004 that have met PA unit limits

PV Types: 11 – Mental Health Providers

Run Date: 05/22/2009 – 07/07/2009

Previously, a message was posted regarding procedure code H0004 that have met the PA limits. 

This issue has now been resolved. You may now file your claims and OHCA will reprocess the ones previously submitted. 

Thank you.

Title: Therapeutic Shoes

Run Date: 05/19/2009 – 07/03/2009

PV Types: All

Message:

Effective immediately, the HCA-43: Statement of Certifying Physician for Therapeutic Shoes will be required for all Prior Authorization requests submitted for diabetic shoes and inserts. Form is available on the OHCA website.

Title: Removal of Revenue Codes from Treatment Room Group

Run Dates: May 15, 2009 – July 1, 2009

PV Types: 01;  Spc: 010, 012, 014, 015

To facilitate appropriate reimbursement for outpatient services, effective 01/01/2009 procedure codes will not be reimbursed off the physician’s fee schedule when billed with the following revenue codes:

523 - FAMILY PRACTICE
520 - FREESTANDING CLINIC
522 - RURAL HEALTH-HOME
529 - FREESTANDING CLINIC/OTHER
700 - CAST ROOM
722 - DELIVERY ROOM
723 - CIRCUMCISION
724 - BIRTHING CENTER
729 - DELIVERY ROOM/LABOR ROOM/OTHER
972 - PROFESSIONAL FEES/RADIOLOGY/DIAGNOSTIC

As always, we appreciate the care you give to our members.

Title: C-Pap Requests for Continuation

Run Dates: 05/07/2009 – 06/22/2009

PV Types: All

Message:

Effective immediately, all C-pap requests for continuation must be submitted as a new authorization request. C-pap continuation must contain a 3 month Summary of Compliance printout report from the equipment. If your equipment is not capable of producing this information, providers must submit the make and model number of the equipment you are utilizing. The 30-day retroactive authorization limit applies.

Title: Audiology Pricing Changes Effective 05/15/2009

Run Date: 05/05/2009 -  06/30/2009

PVs:  20- Audiologists

22 – Hearing Aid Dealers

173 – Speech/Hearing Therapists

220 – Hearing Aid Dealers

As part of our ongoing effort to expedite claims payments for our providers, and based on further review and analysis of claims received, OHCA has established specific pricing for certain audiology items based on the type of hearing loss identified.  The Oklahoma HealthCare Authority (OHCA) has determined that standard DME manual pricing as outlined in Provider Letter # 2008-53 regarding DME Manual Pricing is not appropriate for audiology products. 

As a result most items will be classified as a Cost + 20% payment method; however categories listed below for Digital hearing aids effective May 15, 2009 will have a scheduled price based on hearing loss identified. Hearing aids in the following categories for Digital Monaural and Digital Binaural will be categorized and paid at the following scheduled rates.

(Codes affected are:  V5244, V5255, V5256, V5257, V5258, V5259, V5260, and V5261.)

Each of the prior authorization requests will be reviewed and categorized by the OHCA Auditory Consultant as either (Flat or Gently Sloping Hearing Loss) or (Precipitous Loss) and priced accordingly.  Thank you for the service you provide to Oklahoma’s SoonerCare and Insure Oklahoma members.

You will receive a provider letter regarding this change for your reference later this week.

Title: Bariatric Surgery PA Codes

Run Date: 05/04/2009 – 06/19/2009

Pv Types: All

Message:

Effective 1/1/2009, 99499 has been replaced with S0260 for the Phase I authorization of bariatric surgery. All new requests using 99499 will be cancelled as no PA required. A new PA request will need to be submitted with the new code.

To: All Providers

Run: 04/28/2009 – 05/13/2009

Title: Spring 2009 Training Workshops/Tulsa Registration Closing April 29th

Spring Provider Workshops began in Enid and continue this week in Ada. Registration for the Tulsa location will close tomorrow, Wednesday , April 29th  and OKC will remain open until May 12th. We are offering many new classes that will benefit all providers and encourage everyone to attend.
Class information and online registration for the remaining locations can be found on the OHCA website on our Training page.
Please complete your registration today, to reserve your spot! We look forward to seeing you there!

Title: HCA12a and HCA13a

Run dates: 04/28/2009 – 06/10/2009

PV Types: All

Please note that OHCA is able to process only one Prior Authorization request per member per fax. Multiple Prior Authorization requests and attachments must be separated and faxed individually.

This means each Prior Authorization request submitted must contain its own separate HCA13a, HCA12a and all required documentation in each fax.

Any prior authorization requests containing multiple requests will be automatically cancelled.

Title: Further Clarification Related to Provider Letter 2009-08

Run Dates: 04/24/2009 – 06/10/2009

PV Types: 31, 52, 08, 09 / spc: 080, 184, 185, 093

Tracking of no show appointments came at the request of our providers. The information obtained will be used to develop member education opportunities. Participation in this pilot is strictly voluntary.

If you have any additional questions please feel free to contact Provider Services at 1-877-823-4529, Option #2.

Based on the response to this pilot, other provider types could be added at a later date.

Title: Reminder: Spring 2009 Training Workshops/Enid Registration Closing April 15

Run Dates: 04/13/2009 – 04/16/2009

PV Type: All

Spring Provider Workshops begin Wednesday, April 22, 2009 in Enid. Registration for the Enid location will close on Wednesday, April 15.
Pre-registration for Ada, Tulsa, and OKC is still open at this time. We are offering many new classes that will benefit all providers and encourage everyone to attend.

Class information and online registration for the remaining locations can be found on the OHCA website on our Training page.
Please complete your registration today.

Title: Claims Submission Addresses

Run Date: 04/13/2009 – 06/01/2009 

PV Type: All

Paper Claims:

The EDS SoonerCare claims processing team and the EDS HealthChoice claims processing team are two separate entities in two separate locations. EDS is receiving (1) envelopes which include claims for both programs, (2) HealthChoice claims in the SoonerCare PO Box, and (3) SoonerCare claims in the HealthChoice PO Box. To ensure accurate and timely processing of your claims you must send the claims to the correct PO Box for the correct program. Effective immediately any claims identified as being sent to the wrong PO Box will be returned to you. Any envelopes containing both HealthChoice and SoonerCare claims will be returned to you without processing in either system. Claims that can not be identified may be processed through the wrong claims system causing denial of your claims. 
Please watch the addresses carefully and use the correct box number. For SoonerCare the correct box numbers are:

1500’s: EDS, P.O. Box 54740, Oklahoma City, OK 73154

Medicare Crossover (1500 form):
EDS, P.O. Box 18110,Oklahoma City, OK 73154

Waiver Services
EDS, P.O. Box 54016, Oklahoma City, OK 73154

HMO Co-Pay/Personal Care Service (individual, not agency):
EDS, P.O. Box 18500, Oklahoma City, OK 73154

Lab or DME ;
EDS, P.O. Box 18430, Oklahoma City, OK 73154

Title: SoonerCare Secure Site – Internet Explorer Versions

Run Date: 04/06/2009 – 05/21/2009

PVs:  All

Message:

The SoonerCare Secure Site requires Microsoft Internet Explorer 6 or 7. The Web site does not support Internet Explorer 8 at this time. If you have recently updated your system to include Internet Explorer 8, then you may experience problems navigating and submitting claims on this Web site. If you have any questions please contact the OHCA Internet helpdesk at (405) 522-6205, option 2,1 or (800) 522-0114, option 2,1.

Title: Spring 2009 Provider Workshops

To: All Providers

Run Dates:  03/26/2009 – 05/10/2009

All Providers:

Please join us for the Spring 2009 Provider Training Workshops which will be held: April 22 in Enid; April 29 in Ada; Tulsa on May 6-7; and, in Oklahoma City on May 19-20, 2009.

Specialty training sessions will be offered at various times at each location. Online registration is now available for the Spring 2009 Workshops on our Training page.

All online applicants must have an active and valid email address. Participants registering online will receive their confirmation via email only.

We look forward to seeing you there.

Title: MRI MRA PET 2009

Run Date: March 26 – May 10, 2009

Pvs: All

Message:

The HCA-12 form has recently been updated to include the new assignment code of 42 for MRA/ MRI/ PET procedures.

Due to the new automated process, requests are no longer being returned for correction. For requests to be processed, it is very important to select the appropriate assignment code on the HCA-12A.

Title: DME Repair Codes Added

Run Date: March 25, 2009 thru April 30, 2009

PV Types: 250 – DME/Medical Supply Dealer, 251 – Assistive Technology Dealer

OHCA has added two new labor repair codes approved by CMS effective 04/01/2009. 

K0739:  Repair or non-routine service for DME other than oxygen requiring the skill of a technician, labor component, per 15 minutes; and,

K0740:  Repair or non-routine service for Oxygen Equipment requiring the skill of a technician, labor component, per 15 minutes. 

The current E1340 code will be active until further notice.  All repair codes listed require Prior Authorization. 

Title: Wheeled Mobility Act of 2008 – New Rules

PV Type: 250 – DME / Medical Supply Dealer 251 – Assistive Technology Dealer

Run Date: 03/16/2009 – 04/30/2009

Message:

NEW RULES FOR PURCHASED WHEELCHAIRS EFFECTIVE APRIL 1, 2009.

Alert – All prior authorization requests for purchased wheelchairs (Manual, Power, and POV) received by OHCA on or after April 1, 2009 must have either a documented Specialty Evaluation completed by an OT, PT or Rehab trained Physician or an assessment completed by a RESNA certified ATP (Assistive Technology Practitioner) to specify wheelchair requirements along with medical necessity documentation and a home assessment.  Providers will receive an OHCA Provider Letter outlining the changes later this week.

Title: HCA-13A Cover Sheets

Run Date: 03/13/2009 – 05/01/2009

PV Types: All

Message:

It is critical that cover sheet HCA-13A is used with every authorization request.

In the past it was possible to manually search for and identify submission errors and return faxed documents to providers for correction.  However, under the new automated process, this is no longer possible. The HCA-13A form should be the only cover sheet used with every authorization.

Title: PT Practice Act and referral sources

Run Dates: 02/26/2009 – 04/15/2009

Providers: All

Message:

Referrals for physical therapy must be made by a licensed doctor of medicine, osteopathy, dentistry, chiropractic or podiatry, or a physician assistant, according to the State of Oklahoma Physical Therapy Practice Act (Title 59 O.S., Section 887.2). 

Because of the restriction in the practice act OHCA cannot approve physical therapy requests from any other providers.

Title: “A” HCPCS Codes Limits Revised

PV Types: All

Run Dates: 2/25/09 thru 4/30/09

Message:

Please be advised, OHCA has completed a revision of Min/Max Quantity Limits for Medical and Surgical Supplies HCPCS codes (A4000-A8999) effective for Dates of Service on or after March 1, 2009. A listing for the codes that had limits changed is available on the DME Website under Resources.

Title: IFSP & IEP Services

Run Date: 02/12/2009 – 04/01/2009 

PV Type: 171 – Occupational Therapist, 170 – Physical Therapist, 173 – Speech Therapist

Message:

Providers requesting Occupational, Physical or Speech Therapy for children must include the member’s IFSP or IEP, if applicable. It is not necessary to submit a copy of the entire IFSP or IEP document; providers should submit only the IFSP or IEP page(s) that specify the type(s) and amount(s) of therapy services the child receives, including the goals page(s) related to the therapy being requested.

Title: STBS/Alien Deliveries 

Run Date: 02/12/2009 – 04/01/2009 

PV Type: 328 – OB

STBS/Alien deliveries

OHCA is aware that the payment for the global delivery codes is reduced for members that are eligible aliens.  These are the members that OHCA covered for the delivery only prior to the implementation of STBS.   For Federal reporting, we must keep the delivery payment separate and distinct from the other prenatal care provided to these members.  Beginning February 18, 2009, you will see a supplemental delivery payment on your remittance advice that will make up the difference between what you were paid and the global fee shown in the system.  After the first payment that will encompass all dates of service between April 1, 2008 to February 11, 2009, these supplemental payments will be generated monthly.

Title: Erythropoietin Stimulating Agents

Run Dates: 02/12/2009 – 04/01/2009 

PV types: All

Message:

On March 11, 2009 prior authorization (PA) criteria for the erythropoietin stimulating agents (ESAs) including Aranesp®, Epogen®, & Procrit® (J0881, J0882, J0885, J0886, & Q4081) will go into effect. The PA criteria can be found on the OHCA website at www.okhca.org/providers/rx/pa. There are two PA forms for the ESA category.  The PA forms can be found at www.okhca.org/providers/forms. For further information please refer to Provider Letter 2009-09.

Title: Changing PCP

Run dates: 01/15/2009 – 03/01/2009

PV Types: 31 – Physicians

Please remember, under our new Choice model, members can be assigned to your panel the same day they call the SoonerCare Helpline at 1-800-987-7767.

Action forms are only required when you [the provider] ask OHCA to add members to your panel when your panel is currently at your stated capacity or a member ages out of your requested age range.

Title: Inpatient Notification

Run dates: 01/15/2009 – 03/01/2009

PV Types: 31 – Physicians

As part of the implementation of the enhancements to SoonerCare Choice, coordination of care is an integral part of the medical home concept. Although many of you follow your members when they are inpatient, we have implemented a new process to insure all providers know of services received and where these services were provided. 

Effective 1/1/09, we have requested all Hospitals/Facilities notify us when a SoonerCare member has been admitted to their facility.  This new process may take a while for all Hospitals/Facilities to begin their reporting structure, but once we have received notification our goal is to contact you via telephone within 24 hours of admittance.  If we are unable to contact you via telephone, secure e-mail or Fax (we will make 3 attempts within 2 days) we will send a letter to you.  If you receive a letter, we request you contact us with the correct contact information for your facility. A copy of this letter will be given to your Provider Representative(s) for additional follow up. 

If you have any questions concerning this guideline or specific benefit questions please call Provider Services at the Oklahoma Health Care Authority toll free at 877-823-4529, option #2, or additional information about SoonerCare may be found on our public website at www.okhca.org.