Date Posted

Title

Message

Title:CPT & HCPCS Codes

Run Date:12/29/2014 – 02/15/2015

PV Types:All

Annually the AMA and CMS review, add, change and delete various billing CPT and HCPCS codes.It is OHCA’s annual standard operating procedure to update our codes in accordance with our codified policy. OHCA reminds all providers to be cognizant of new, changed and deleted 2015 CPT codes and 2015 HCPCS codes for billing purposes. New codes are effective as of January 1, 2015, date of service, and deleted codes are end dated effective December 31, 2014.

 Title:CPT & HCPCS Codes RE Radiation Treatment

 Run Date:12/23/2014 – 02/06/2015

 PV Types:All

 For 2015, CPT and HCPCS codes have changed related to Radiation Treatment planning and delivery.  The OHCA will follow ASTRO guidelines, allowing the following codes: CPT 77306, 77307, 77316, 77317 and 77318.  Brachytherapy isodose planning CPT codes 77316, 77317 and 77318 will be reimbursable. CPT 77401 will be allowed, but 77402, 77407 and 77412 will end 12/31/14.  In lieu of these CPT codes for Radiation Treatment Delivery, use HCPCS G6003 through G6014 as appropriate by definition of the code.  Do not use CPT 77385, 77386 or 77387.  In lieu of these CPT codes, use G6016 or G6015.  Use HCPCS G6001 or G6002 for guidance, based on method.  HCPCS G6017 is not reimbursable.

Title:2014 Flexibility Rule Changes

Run Date:12/12/2014 – 03/31/2015

PV Types:01- Hospital

31- Physicians

52- State Employed Physicians

09- Advance Practice Nurse

27- Dentist

10– Mid-level Practitioners

Providers and hospitals affected by the delay in implementing a 2014 certified EHR technology (CEHRT) may begin submitting attestations on December 18, 2014. Attestations for the 2014 program year will be accepted through January 31, 2015 for hospitals and March 31, 2015 for eligible professionals. Please visit www.okhca.org/ehr-incentive for more information or contact us at 405-522-7347.

Title:PA Processing for FMV Enteral Formula Approved &

Priced by MAU Prior to 09/24/2014

Run Date:12/03/2014 – 03/02/2015

PV Types:25 – DME/Medical Supply Dealer

For Active PA’s the Provider will need to follow the steps below:

1.Send in an amendment on the current, active PAR.

2.The provider will need to take the HCA-12A form they sent in originally, DO NOT ALTER THE DATE SPAN

3.Draw a line through the old units, enter the units that will be billed thru 11/30/2014

4.Add a line item with the same code and enter the remaining units that will need to be billed from 12/1/2014 to the end of the current authorization period.

EXAMPLES:

LINE:A

CODE: B4160

MODIFIER:

DESCRIPTION:PEDIASURE 1.0

UNITS:2500 (strike-thru) 300 (insert)

BILLED CHARGES:

LINE:B

CODE:B4035

MODIFIER:

DESCRIPTION:SUPPLY KIT

UNITS:20

BILLED CHARGES:

LINE:C

CODE:B4160

MODIFIER:

DESCRIPTION:PEDIASURE 1.0

UNITS:2200

BILLED CHARGES:

In the section 6, simply indicate pricing changes due to FMV, initial changes and date you initialed and submit to MAU. If you have questions please call: OHCA Call Tree at (800)522-0114, Option 6.

Title:Ambulance Mileage Codes

Run Dates:12/02/2014 – 01/17/2015  

PV Types/spc:260 – Ambulance

Effective 1/1/2015, HCPCS A0380 (BLS mileage) and A0390 (ALS mileage) will be invalid.  The valid code for ground ambulance transportation mileage is A0425 (Ground mileage).

Title:Individuals Billing for Outpatient Behavioral Health Services

Run Date:11/24/2014 – 01/15/2015

PV Type:08, 11, 53, 21, 17

Spc:110, 111, 112, 114, 115, 116, 117, 118, 119, 121, 123, 193,

011,221,222,223,224,225,226,227,228,585,535,536,533,553,572

Pursuant to OAC 317:30-5-241, 30-5-276 and 30-5-281, effective 11/3/2014, all individual rendering outpatient behavioral health providers are limited to billing no more than 35 hours per week. Billable hours only include the time spent face-to-face with the client providing treatment services.

This limit does not include assessments, service plan development, psychological testing, or crisis intervention.

The 35-hour limit will be calculated using a 4-week rolling average. For more information, please visit http://www.odmhsas.org/arc.htm.

Please verify that this new rule applies to you/your practice.

Title:Additional Requirement for Ordering/Referring Claims Submissions

Run Date:11/05/2014 – 12/20/2014

PV Types:23 – Nutritionist

19 – Optician

20 – Audiologist

25 – DME/Medical Supply Dealer

SPC:230 - Nutritionist

190 - Opticians

200 - Audiologist

182 - Speech Hearing Clinic

173 – Speech/Hearing Therapist

189 - Audiology Group

203 - Diagnostic Sleep Study Clinic

250 – DME/Medical Supply Dealer

570 - Genetic Counselor

This is notification that starting November 5, 2014 we will be updating the claims editing system to require the National Provider Identifier (NPI) of ordering or referring providers on the following claims, for dates of services January 1, 2014 and beyond.

If the billing provider type is Nutritionist, Optician, Audiologist or if the billing provider specialty is Speech Hearing Clinic, or Audiology Group Diagnostic Sleep Study Clinic, DME Medical Supply Dealer, Sleep Medicine, or Genetic Counselor and there is not an ordering/referring NPI on the claim, the system will deny the claim.

PV Types:All

Title:Sacral Nerve Stimulators

Run Dates:10/31/2014 – 12/15/2014

As of November 1, 2014, the placement, revision and removal of Sacral Nerve Stimulators will require prior authorization (PA).This requirement applies to both the test stimulation as well as the permanent implantation of the device.Affected procedure codes include:

•64561 Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement), including image guidance if performed

•64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)

•64585 Revision or removal of peripheral neurostimulator electrode array

•64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

•64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

Title:Sleep Study Prior Authorization (PAR) Updates

Run Dates:10/29/2014 – 11/30/2014

PV Types:All

Based on the short time since the onset of Prior Authorization of Sleep Studies this summer, the OHCA has identified problem areas and this global communication will address those issues in an attempt to assist providers in efficient management of their PAR resources.All clinical and documentation requirements relating to sleep study PARs are recorded in the Sleep Study Guidelines located on the public website:(http://www.okhca.org/providers.aspx?id=16427 ).

Covered Indications:

• Obstructive Sleep Apnea
• Narcolepsy
• Parasomnias (only where convincing evidence is documented for danger to member or those around the member)

Additional specific indications allowed for children are included in the guidelines.

Non-Covered Indications:Please do not submit PARs for non-covered indications.

• Insomnia is commonly submitted and is not a covered indication.
• Apnea of Prematurity is commonly submitted and is not a covered indication.
• Risk Factors- PARs are NOT approved based on risk factors for a covered indication.
• See guidelines for a listing of additional non-covered indications.

Medical Documentation Required for all Covered Indications:

• History and Physical exam performed within 6 months
• *Detailed sleep history with pertinent positives and negatives (“snoring” is incomplete and not a detailed history)
• *Specific physical exam of the airway including pertinent positives and negatives for jaw, palate, tonsils; T & A history or plan, etc.A Mallampati score is very useful since it correlates with OSA;(“OP:MMM,”“OP:WNL,” are incomplete and are not an exam of the airway)
• *Epworth Scale for members 16 years of age and older

Please see guidelines for specific requirements for detailed sleep history and physical exam of the airway.

*= may be a part of the history and physical exam or may be separate documents.

Procedural Assistance:

If a split study (codes95811 or 95873) is requested and approved, and the member does not meet the requirements of the split study, it can be continued as an overnight diagnostic.An amendment should then be filed requesting approval of an overnight diagnostic (95810 or 95872).The approved 95811 then applies to the titration done on the second night (the codes are the same).

For narcolepsy, the MSLT (95805) must be preceded by an overnight diagnostic on the previous night.Please request both codes in the PAR.If the overnight makes the MSLT unnecessary, just do not perform the MSLT and do not bill for it.

Requests for repeat testing must clearly document the specific reasons for the repeated test.Please review and follow OHCA guidelines.

Paper PA Requests:

Assignment Codes on HCA-12A

46 Sleep Study (used by Sleep Centers) = Section 4 must be completed

03 or 04 Dr. Office = No need to enter Section 4

If requesting modifier TC or 26, please include a line for each of the modifiers.

Provider Portal Submissions:

Enter each code as a separate line. Please DO NOT use the “THRU” box.

Medical Home ER Utilization Study Webinar  

Title:REPOST/REMINDER/UPDATE

Medical Home ER Utilization Study Webinar

Run Date:10/13/2014 – 11/28/2014

Pv Types:08 – Clinic

10 – Mid-Level Practitioner

31 – Physicians

52 – State Employed Physicians

09 – Advance Practice Nurse

07 – Capitation Provider

Spc:080 – FQHC

081 – RHC

084 – I.H.S./Tribal Clinic

072 – I.H.S. Case Manager

093 – ARNP (Certified Nurse Practitioner)

100 – Physician Assistant

ATTENTION:SoonerCare Choice Primary Care Providers

The Oklahoma Health Care Authority is conducting a study of current and potential emergency department diversion models, for persons who are enrolled in SoonerCare that may be implemented in the state, and to explore options for cost containment and delivery alternatives that are consistent with the existing Patient-Centered Medical Home program. From 4:00pm – 6:00pm on October 29^th,and, from 5:30pm – 7:30pmon November 5^th OHCA will be providing information regarding current ER utilization by SoonerCare members covered through OHCA and will provide a channel for participants to provide feedback, including recommendations, to OHCA on reducing SoonerCare member ER utilization.

NOTE: These WEBINARS will each be limited to the first 50 registrations. Click to Register

Title: UPDATED: OHCA Communications are Going Electronic

Run Dates:10/23/2014 – 12/10/2014

PV Types:All

REMINDER: Effective November 1, 2014, all communications to providers will be through email distribution.

It is very important that your email address be on your provider contract file. Read provider letter 2014-44 on our public web site (www.okhca.org) for instructions on updating your contract file.

Update (10/24/2014)

ATTENTION PROVIDERS AFFILIATED WITH A GROUP CONTRACT: In order to receive important policy and program information directly, you must add a preferred email address to your individual contract file. Otherwise, all official OHCA communications will only be sent to the group administrator.

By ensuring that there is a preferred email address in the individual contract file, both provider and the group administrator will receive OHCA email communications.

Title:Reminder – OHCA Communications is Going Electronic

Run Dates:10/23/2014 – 12/10/2014

PV Types:All

REMINDER: Effective November 1, 2014 all communications to providers will be through electronic e-mail distribution.

It is very important that your e-mail address be on your provider contract file. Read provider letter 2014-44 for instructions on updating your contract file and accessing information on our Public web site.

Title: Sleep Study Prior Authorization Requests

Run Date: 10/15/2014 – 12/01/2014

PV Types:  All

Effective immediately, prior authorization requests (PARs) for sleep studies will no longer be reviewed on an urgent basis by the Medical Authorization Unit (MAU).  Because sleep studies are not emergent, these PARs will be reviewed in the order of the date received.Currently, the MAU is processing sleep study requests within five business days.You may review the status of your PAR via the OHCA Provider Portal.

Thank you for the quality of care that you provide to SoonerCare and Insure Oklahoma members. If you have questions, please contact the OHCA MAU at 800-522-0114.

Title:New ADA 2012 Dental Claim Form

Run Date:10/14/2014-12/31/2014

PV Types:27 – Dentist

86 – Dental Clinic

271 – General Dentistry

272 – Oral Surgeon

273 – Orthodontist

274 – Pediatric Dentist

ATTENTION: ALL DENTAL PROVIDERS

OHCA will accept the American Dental Association 2012 claim form effective 10-17-2014.  

We will accept the ADA 2006 & ADA 2012 claim form until 12-17-2014. 

After 01/01/2015 ONLY the ADA 2012 claim form will be accepted.

Title:Moderate Sedation Services

Run Date:10/15/2014 – 12/01/2014

PV Types:31 – Physician

52 – State Employed Physician

09 – CRNA

SPC:094 – CRNA

Effective 11/1/2014, Moderate Sedation services (CPT 99148, 99149 and 99150) will no longer require physician review.  No clinical attachments will be required.

Title:Headache Diagnosis

Run Date:10/15/2014 – 12/01/2014

PV Types:31 – Physician

52 – State Employed Phys

10 – PAs

09 – APN

01 – Hospitals

Effective 11/1/2014, Physician review of claims with Headache diagnosis (339.00-346.73) will end. No clinical attachments will be required.

Title:Medical Home ER Utilization Study Webinar

Run Date:10/13/2014 – 11/28/2014

PV Types:08 – Clinic

10 – Mid-Level Practitioner

31 – Physicians

52 – State Employed Physicians

09 – Advance Practice Nurse

07 – Capitation Provider

Spc:080 – FQHC

081 – RHC

084 – I.H.S./Tribal Clinic

072 – I.H.S. Case Manager

093 – ARNP (Certified Nurse Practitioner)

100 – Physician Assistant

ATTENTION:SoonerCare Choice Primary Care Providers

The Oklahoma Health Care Authority is conducting a study of current and potential emergency department diversion models, for persons who are enrolled in SoonerCare that may be implemented in the state, and to explore options for cost containment and delivery alternatives that are consistent with the existing Patient-Centered Medical Home program. From 4:00 pm – 6:00 pm on October 29^th and November 5^th OHCA will be providing information regarding current ER utilization by SoonerCare members covered through OHCA and will provide a channel for participants to provide feedback, including recommendations, to OHCA on reducing SoonerCare member ER utilization.

NOTE: These WEBINARS will each be limited to the first 50 registrations. Click to Register

Title: VFC Processing Error/Recoupments

Run Dates:10/08/2014 – 11/22/2014

PV Types:All

OHCA is processing an adjustment for Medical Homes and other vaccine for children (VFC) providers. Due to a processing error, OHCA has been reimbursing for the vaccines that are provided free through the VFC program since December 2012.  This adjustment will recoup those payments. Refer to provider letters 2009-20 and 2009-23 for further clarification and accurate billing instructions.  Providers can identify these adjustments by EOB 8131 – “OHCA initiated offset due to processing error”.  These recoupments will be on providers’ October 22, 2014 remits.

Preparation of Allergy Antigen  

Title:Clarification of Billing for CPT 95165 –

Preparation of Allergy Antigen

Run Date:10/01/2014 – 11/15/2014

PV Types:All

Reimbursement for CPT 95165 (professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens) is based on the number of units of antigen(s) for allergen immunotherapy contained in an original multi-dose vial (commonly referred to in the industry as a maintenance or concentrate vial).The maximum reimbursement for any multi-dose vial is 10 units.  A unit is equal to a 1-cc aliquot antigen from an original multi-dose vial.Some antigens cannot be mixed together (i.e., they must be prepared in separate vials).An example of this is mold and pollen.Therefore, some individuals will require two (2) multi-dose vials to be prepared and will receive injections prepared from both vials.

Reimbursement limits are set at 10 units per original multi-dose vial per 90 days (20 units per 90 days when it is medically necessary to prepare two (2) multi-dose vials) and a total of 40 units (80 units when it is medically necessary to prepare two (2) multi-dose vials) per 12 months, based on a rolling period.A prior authorization (PA) override may be allowed for medically necessary indications.

For more information regarding the PA process, please visit the MAU web page at www.okhca.org/mau and click on the section you would like to review.

Title:A4264 Rate Change

Run Date:09/29/2014 – 11/13/2014

PV Types:31 - Physicians

SPC:083 – Family Planning Clinic

 328 – OB/GYN

Effective 09/01/2014, OHCA will reimburse A4264 (permanent implantable contraceptive intratubal occlusion device(s) and delivery system) at $1,500.00 per package. 

Each package contains two coils, and only one package is allowed. 

Modifier 52 is allowed/required if only one coil is placed. This will result in a 50 percent reduction in payment.

 --------------------------------------------------------------

Should additional coils be required, one (1) additional package mightbe considered with prior authorization (PA).  This PA request should be submitted to OHCA’s Medical Authorization Unit (MAU).   

Title:OHCA EXTERNAL PROVIDER TESTING UPDATE

Run Dates:09/23/2014 – 11/07/2014

PV Types:ALL

Oklahoma Health Care Authority External Provider Testing Update: 

• OHCA recently completed an initial beta round of external provider testing on August 29, 2014. Currently, three additional rounds of testing are tentatively scheduled as follows:
• Round 1: November 3, 2014 - December 26, 2014
• Round 2: February 2, 2015 – April 30, 2015
• Round 3: June 1, 2015 – August 28, 2015
• OHCA is currently reaching out to specific billing agents and clearing houses to define which providers will be selected to participate in the next rounds of testing. Each billing agent or clearing house will be allowed to select no more than two of the providers for which they submit claims for in production today.
• It’s recommended that providers contact their billing agent or clearing house ASAP to let them know whether you’re interested in participating in testing, and to see if they’re capable and willing to submit your test claims if they’re contacted by HP to participate in the testing. You will only be selected for testing if OHCA selects your billing agent or clearing house and they in turn select you as one the two providers their allotted as noted in the second bullet above.
• For providers that would like to be considered for testing who are ready to submit test claims but do not use a billing agent or clearing house, and upload their own EDI 837 files, or enter claims directly, via the secure Provider Portal, should send an email to the ICD-10 email account at: ICD10project@okhca.org indicating their interest in testing. From the emails received, OHCA will select a defined set of providers to participate in testing depending upon the number of requests. In your email request to test with OHCA, please include all pertinent contact information and which round of testing you’d like to participate in. Pertinent contact information would include:
• SoonerCare Provider number and location (e.g. 123456789A)
• Name of organization
• Name, email, & phone number of the person responsible for ICD-10 testing

Title:Clarification Regarding Reimbursement for LBHP Candidate

Run Date:09/17/2014 – 10/31/2014

PV Types:11, 53

Spc:093, 100, 110, 111, 115, 117, 118, 119, 121

534, 535, 585, 586

Clarification Regarding Reimbursement for LBHP Candidates

Effective 10/01/14, services provided by LBHP candidates working for individually contracted LBHP providers will no longer be reimbursable by SoonerCare. In order for LBHP candidates to be reimbursed, they must provide services to clients through an outpatient behavioral health agency. This change only affects SoonerCare reimbursement and does NOT interfere with a licensure candidate's ability to choose from any approved licensure supervisor and receive their licensure supervision in any setting approved by their respective licensing board.

Title: 2014 Provider Workshop – Tulsa Registration Closing

Run Date: 09/16/2014 – 10/23/2014

PV Types: All

Registration for the Sept 23^rd & 24th, 2014 Fall Workshop for Tulsa will close on Tuesday, Sept 16th at 5 p.m. However, walk-ins are still welcome! Please come 15-20 minutes before the first class you wish to take and bring your Provider ID.

Registration for locations in Lawton, Durant and OKC are still available.

Each attendee must have their own registration and please thoroughly read the class descriptions and recommended audiences before choosing your classes. Register today!

Information and registration is available at: 

Class Descriptions:http://www.okhca.org/Classes 
Registration Tool:http://www.okhca.org/Register

To make ANY changes to your registration, please call 405.416.6730 or emailHPokxixTraining@hp.com.

Title:UPDATE #2: 2014 FALL TRAINING CLASS SCHEDULE

Run Dates:09/10/2014 – 10/24/2014

PV Types:All

RE:Opioid Prescribing/Quantity Limits, Lock-in Program,

and Medication PA Process

Opioid painkiller quantity limits will go into effect in the near future for all OHCA members.  Learn how this will affect your prescribing habits and practice at the OHCA the Fall Provider Workshop!  The class, conducted by Pharmacists, will focus on opioid, narcotic and painkiller prescribing including upcoming SoonerCare quantity limit restrictions.  Next the patient review and restrictions known as the Pharmacy Lock-In program will be reviewed along with the prior authorization process for all medications covered by OHCA.

The Workshops begin on September 23rd in Tulsa.  Please join us!

Class information and registration is available at:

http://www.okhca.org/register

http://www.okhca.org/classes

Title:Diabetic Supply Billing Process Changes Postponed

Run Dates:09/12/2014 – 10/31/2014

PV SPC:250 – DMEPOS Providers

240 - Pharmacy

Types: 24 - Pharmacy

The transfer of diabetic supply billing processing to the Pharmacy point-of-sale method will no longer occur on October 1, 2014. This change has been postponed. 

OHCA will issue a 60-day notice prior to implementing the change.

Title:UPDATE: 2014 FALL TRAINING CLASS SCHEDULE

Run Dates:09/08/2014 – 10/24/2014

PV Types:All

The OHCA Provider Enrollment department will be conducting a class in the upcoming Fall Provider Workshop! The class will cover how to update and maintain your provider file as well as how to create a new contract or renew a contract. There will be specific information for SoonerCare Choice and Insure Oklahoma providers and behavioral health providers in a medical clinic. The class will also cover OHCA’s new “Going Green” initiative. Workshops will begin in Tulsa starting September 23^rd!

Register today!

Information and registration is available at: 

http://www.okhca.org/register

http://www.okhca.org/classes

Title:TR3 Notes

Run Dates:09/05/2014 - 10/20/2014

PV Types:28 – Lab

29 – Xray

Spc:280 – Independent Lab

281 – Mobile Lab

290 – Freestanding Xray Clinic

291 – Mobile Xray Clinic

292 – Mammography

341 – Radiologist

342 – Thoracic Surgeon

ATTN: Radiology providers filing batch claims

When reporting the provider who ordered services for radiology and lab, use Loop ID-2310A at the claim level.

Title:School-Based Training Schedule

Run Date:09/05/2014 – 11/01/2014

PV Types:12 / 120

School-Based Training is scheduled for the following dates and times.

October 2, 2014 –Stillwater (10:00am to 12:00pm)

October 9, 2014 –McAlester(10:00am to 12:00pm)

October 21, 2014 –Poteau (1:00pm to 3:00pm)

October 29, 2012 –Oklahoma City (10:00am to 12:00pm)

Register for the training through OHCA website at

http://www.okhca.org/schoolbased

TITLE: Sleep study prior authorization request (PAR) additional information

Run Dates:09/02/2014 – 10/17/2014

PV Types:All

Who can submit the PAR:

A provider (PCP or specialist) can request the PAR; OR

A provider can refer to a sleep medicine specialist and the sleep medicine specialist can request the PAR; OR

A sleep center with a sleep medicine specialist on staff who can do the PAR; OR

A sleep center working directly with a provider who can do the PAR.

The primary care provider (PCP) does not need to submit a referral to send a member to a sleep specialist or for a sleep study. Since this service requires a PAR, it does not need a PCP referral.

Regardless of who submits the request, the criteria are the same. Sleep study guidelines and submittal information for PARs can be found on our public website at http://www.okhca.org/providers.aspx?id=16427.

Please note Page 6 of the guidelines which lists the specific requirements for each of the three covered indications: narcolepsy, obstructive sleep apnea and parasomnias where there is clear evidence of danger to the member or others (and the diagnosis cannot be made based on clinical evaluation).

Also, please note Page 7 of the guidelines. This is where you will find a complete listing of what we do not cover, unless the member has evidence of another covered indication. A few examples are:

·Chronic insomnia

·Restless legs syndrome

·Circadian rhythm sleep disorders

·Impotence

·Migraine headaches

Effective September 15, 2014, incomplete PARs for sleep studies will no longer be pended for additional information; they will be cancelled. Additionally, the reason for the cancellation will be indicated on the PAR.

If you need additional information about this Global, please call the OHCA Provider Helpline at 800-522-0114. Specific requests for onsite training should be directed to: ProviderServicesAdmins@okhca.org.

Title:       Oxygen Testing Exemption Process

Run Date:    08/21/2014-10/15/2014

PV Types:    250 – DMEPOS Providers

There is a new process for requesting oxygen testing exemption review.

Effective August 25, 2014, such requests should be submitted to the Medical Authorization Unit (MAU) as new prior authorization (PA) requests. PA for oxygen is not required for SoonerCare members residing in nursing facilities.

Each PA request requires the following:

1.HCA-13A special fax cover sheet, if faxing your request. This must be the top document sent or the PA request will be rejected by system;

2.HCA-12A PA form signed and dated by the ordering provider; OR send an online request via the Provider Portal secure site (no need to send the paper copy of HCA-12A for web submissions);

3.RR modifier for oxygen rental (not the LL)

4.Initial 90 days of service are not subject to prior authorization.

5.If keyed online, a copy of the signed orders must be attached to the uploaded documents; and

6.All signatures must be legible or accompanied by a printed name with title.

7.Essential documents for review:

1. Objective medical records with sufficient documentation to support the member’s long-term needs for service and the expectation that the medical condition requiring oxygen will not improve; 
2. Oxygen prescription by a qualified medical practitioner (M.D., D.O., physician assistant, or advanced nurse practitioner);
3.  Certificate of Medical Necessity (CMN), which includes:

§HCA-32 (revised 2014) Oxygen for adults and ALL children (younger than 21)       

§HCFA 484.03 allowed for Adults (Note: HCFA 484.2 is out of date and not acceptable); and,

d.Letter of Medical Necessity (LMN), containing member-specific information as to why an exemption to the testing is being requested.

If your exemption request is denied, your PA request will be cancelled. At that time, you will need to obtain new testing and submit a NEW PA request with a new CMN and all required documents.

For more information regarding the PA process, please visit the MAU Web page at www.okhca.org/mau and click on the section you would like to review.

 Title:2014 Fall Provider Training Workshop

Run Date:08/20/2014 – 10/23/2014

PV Types:All

PLEASE JOIN US FOR THE 2014 FALL PROVIDER TRAINING WORKSHOP!

You and your staff are invited to attend the Fall 2014 SoonerCare Provider Training Workshops hosted by OHCA and HP. Tulsa, OK will be the first stop on Sept 23-24 followed by: Lawton, Oct 8; Durant, Oct 16; and, conclude in Oklahoma City, Oct 22–23.

Based on your suggestions, classes include: 
OHCA Medical Authorization, OHCA Policy, Provider Enrollment, SoonerCare Basics and Beyond, Tobacco Cessation, OHCA Specialized Therapy Management Quality Assurance Program, Navigating OHCA Public Website, and Prescriber Policy Update. 

OHCA and HP highly recommend all providers attend this workshop! Class descriptions will explain the covered topics and recommended audience. 
Classes fill up soon, so mark your calendar and register now! 

Register today!

Information and registration is available at: 

http://www.okhca.org/register

http://www.okhca.org/classes

Title:Balance Billing of Members

Run Date: 08/11/2014 – 09/26/2014

PV Type:All

Providers cannot bill or attempt to collect payment from a SoonerCare Member for any covered service, other than co-payments allowed by The Oklahoma Health Care Authority (OHCA).

Pursuant to 42 CFR 447.15, payments made by OHCA shall be considered payment in full, except for OHCA allowed Member co-payments. This provision is a part of all SoonerCare contracts and applies even if the provider elects not to bill OHCA for a covered service. 

Any questions or concerns regarding balance billing should be directed to Provider Services at 800-522-0114, option 1, before billing the member.

Title:SUD Treatment Requirements

Run Dates:08/04/2014 – 09/19/2014

PV Types:11

SPC:110, 118, 123

Pursuant to State law, only facilities appropriately certified by the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) may receive and assist alcohol and drug-dependent persons by providing treatment, recovery support and rehabilitation. Organizations without proper certification may not provide treatment services to clients with substance use disorder service focus. Any claims for SUD treatment services provided by non-certified organizations are subject to recoupment. For questions related to ODMHSAS certification please contact Brenda Pitts at bpitts@odmhsas.org or 405-522-3800.

Title:Blood Glucose Testing Supplies

Run Date:08/01/2014 – 09/30/2014

PV Types:ITU – 07/072, 08/084

DME – 250

Physician – 31

Tribal Hospitals – 01/016

Physicians who are treating members with pre-diabetes symptoms may prescribe blood glucose (BG) testing supplies in accordance with the member’s treatment. Dispensing providers would need to obtain a prescription with the DX code of 79029 (Other Abnormal Glucose). Supply limits for this group are identical to those for members who are diagnosed with Type 2 diabetes: two (2) boxes of 50 BG strips and one (1) box of 100 lancets per quarter.

Title:Telephone Number Clarification re: Provider Letter 2014-13

Run Date:07/25/2014 – 09/10/2014

PV Types:170-Physical Therapy, 171-Occupational Therapy, 173 & 182-Speech Language Pathology, and, 200-Audiology Providers

The telephone number specified originally in Provider Letter 2014-13, [Therapy-Related Parental Participation – Effective Date 08/01/2014] has been updated.

The new number to call with any questions is (888) 693-3281, option 2. Thank you.

Title:WEBINAR: HOW TO SUBMIT A DENTAL PA ON THE PROVIDER PORTAL

Run Date:07/22/2014 – 08/07/2014

PV Types:27 – Dentist

86 – Dental Clinic

271 – General Dentistry

272 – Oral Surgeon

273 – Orthodontist

274 – Pediatric Dentist

OHCA will be conducting a WEBINAR on August 6, 2014 to review the process of submitting Dental PA’s on the Provider Portal. This class will discuss the PA process, the forms required, how to complete the forms properly and what records will be required. 

Please register via link below:

Class Time:  August 6, 2014 @ 2:00 pm

Registration:/content/sok-wcm/en/okhca/providers/provider-training

Please share this notification with any dental provider!

Dear Insure Oklahoma Individual Plan Provider,

This letter is to review the copays for individuals covered by the Insure Oklahoma Individual Plan. As of January 1, 2014, co-pays for prescriptions, physician, and outpatient visits were changed. Most copays are now $4, although some prescriptions and durable medical equipment (DME) are $8. The emergency room co-pay remains the same at $30 and is waived if the member is admitted. Current co-pays are as follows:

For dates of service on or after January 1, 2014, IO IP members are responsible for paying all individual co-pay amounts for the aforementioned services. Please review the remittance advice for total member co-pay amounts due. These changes will not affect claims for dates of service rendered prior to January 1, 2014. 

Thank you for your continued service to Insure Oklahoma members. If you have questions, please contact the Insure Oklahoma helpline at (888) 365-3742.

Title:Prior Authorization Webinar for Spinal Fusion Surgery

Run Date:07/15/2014 – 07/24/2014

PV Type:31-Physician; 01-Hospital

SPC:325 Neurological Surgeon

342 Thoracic Surgeon

544 Pediatric Orthopedics

551 Pediatric Surgery (Neurology)

559 Surgery Head and Neck

010 Acute Care

015 Children's Specialty  

Attention:   Neurosurgeons, Orthopedists and Inpatient Hospitals

Effective, July 2014, a new process will be implemented regarding the PA process for Inpatient Spinal Fusion Surgery.  We will be conducting webinars to go over the new process on July 22 and July 24.  This class will discuss the PA process, the forms required, how to complete the forms properly and what records will be required. 

**Attendees only need to register for one webinar.

Class Times:  July 22, 2014    2:00 p.m.

                   July 24, 2014  2:00 p.m.

Registration: /content/sok-wcm/en/okhca/providers/provider-training

Title:Psychosocial Rehabilitation Services Eligibility

Run Date:07/10/2014 – 09/30/2014

PV Types:110, 111, 118, 123

Effective August 1, 2014, eligibility criteria changes for psychosocial rehabilitation services (PSR) offered through SoonerCare.

Adult PSR services will be limited to members who:

·have a history of psychiatric hospitalization or admissions to crisis centers;

·have been determined disabled by the Social Security Administration for mental health reasons;

·are residing in residential care facilities; or

·are receiving services through a specialty court program.

Children's PSR services will be limited to members who have:

·a history of psychiatric hospitalization or admissions to crisis centers;

·been determined disabled by the Social Security Administration for mental health reasons;

·a current Individual Education Plan (IEP) or 504 Plan for emotional disturbance; or

·been evaluated by a school psychologist, licensed psychologist, or psychiatrist and determined to be "at risk.”

Guidance regarding prior authorization requirements for these services will be provided in the next couple of weeks. The Prior Authorization Manual will be updated to include the new processes and added to the OHCA website (http://www.okhca.org) August 1.

Title:School-Based Fee Schedule

Run Date:07/02/2014-08/17/2014

PV Types:12 / SPC 120

Effective 7/1/2014 School-Based billing rates have changed.

Review the updated fee-schedule rates on the OHCA website at:/content/sok-wcm/en/okhca/providers/school-based-services 

Title:OXYGEN PA Postponed until 8/1/2014

Run Date:07/01/2014 – 10/01/2014

PV Types:250 – DMEPOS Providers

Oxygen equipment and services will require PA effective August 1, 2014. OHCA has determined that prior authorizations will not be required for residents of nursing facilities or Insure Oklahoma members; however, the modifier instructions below apply to all claims.  

All claims with dates of service before July 31, 2014 will require the use the “LL” modifier for oxygen equipment rental. HCPCS codes include E0424, E0431, E0434, E0439, E1390, E1391, E1392, and K0738.  The modifier “RR” will be used beginning August 1, 2014. 

No prior authorizations for OXYGEN will be accepted by the OHCA system prior to August 1, 2014.

Provider letters detailing these changes are forthcoming.

If you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924.

TITLE:Proposed Budget Cuts & Their Effective Dates

Run Dates:06/27/2017 – 08/15/2014

PV Types:All

Elimination of Perinatal Dental Benefits (cited in OHCA Member Letter 2014-02)

* effective Jul 18

Prior Authorize Oxygen after 90 days * exclude nursing homes

* effective Aug 1

Convert Blood Glucose supplies to competitive bid national rate

* effective Jul 1

Exclude Members with other primary credible insurance from Medical Homes

* effective Jul 1

Federally Qualified Health Centers / Rural Health Centers Visit Limit;

4 per month for adults; 1 per day for everyone

* effective Jul 1

Hospital Readmissions

* effective Oct 1

Prior Authorization for all Sleep Studies

* effective Aug 1

Prior Authorization for all Back & Spinal Surgeries

* effective Aug 1

Limit number of pairs of glasses we pay for children to 2 pair / year

* effective Jul 1

Increase Copays; most $3 copays are going to $4;

Rx $0 copay generics are also going to $4

* effective Jul 1

Eliminate payment for hospital leave days to nursing facilities

* effective Jul 1

Reduce payment of co-insurance on Part B crossover claims from

100% to 46.25%

* effective Jul 1

Across the board rate reduction of 7.75%

* effective Jul 1

These reductions do not apply to the Insure Oklahoma Program.

If you have questions please call the OHCA Call Center at (800)522-0114.

Title:NH Only Cost Share Reporting

Run Date:06/27/2014 – 07/02/2014

PV Type:Nursing Homes:

03-Extended Care Facility

SPC:

Attention NH Facilities:

Effective July 2014, a new process will be implemented in the Provider Portal regarding the submission of Cost Share Reporting to the Oklahoma Health Care Authority.  In this class, we will discuss changes to the Cost Share Reporting for Long Term Care (LTC) Providers.  We will cover how to access the site and the various changes in the actual reporting process. **-Attendees only need to register for one webinar

Class Times:*July 1, 2014                 10:00 a.m.

Registration:  /content/sok-wcm/en/okhca/providers/provider-training

Title: CLARIFICATION: Manually Priced Items –

Process Postponed until 10/01/2014 

Run Date:   07/01/2014-10/31/2014 

PV Types:   250 – DMEPOS Providers 

Manually Priced Items

Due to administrative delays, the current processing method for manually priced items will continue to be in effect until October 1, 2014.  Please continue to provide pricing information with your PA requests, if appropriate, or submit costs with your claims as you do now. 

Provider Letters:  A provider letter detailing these changes is forthcoming.  

If you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924.  

Title:NH Only Cost Share Reporting

Run Date:06/18/2014 – 08/02/2014

PV Type:Nursing Homes:

03-Extended Care Facility

SPC:

Attention NH Facilities:

Effective July 2014, a new process will be implemented in the Provider Portal regarding the submission of Cost Share Reporting to the Oklahoma Health Care Authority. In this class, we will discuss changes to the Cost Share Reporting for Long Term Care (LTC) Providers. We will cover how to access the site and the various changes in the actual reporting process. **-Attendees only need to register for one webinar.

Class Times:*  June 26, 2014 at 10 a.m.

June 26, 2014 at 2 p.m.

                     June 27, 2014 at 10 a.m.         

Registration: /content/sok-wcm/en/okhca/providers/provider-training

Title:Clarification to BH Providers

Run Date:06/17/2014 – 07/31/2014

PV Type:08, 11, 53

Spc:110, 111, 112, 115, 121, 193, 585, 535, 536

The RBRVS global dated June 12, 2014 mentioned the 7.75% rate reduction. For Behavioral Health services this reduction only applies to psychiatrists and Inpatient Facility Psych Beds which are paid off of the DRG fee schedule.

Title:New Fee Schedule

Run Date:06/12/2014 – 07/31/2014

PV Types: All

Remember that we update our fee schedule every July to rebase to the new Medicare RVUs. The new fee schedule will be on our public website as soon as possible.

Dates of service prior to July 1, 2014 are paid at last year’s rate and dates of service after July 1, 2014 are paid at the new rate. The new fee schedule will also reflect the agency’s across the board rate reduction of 7.75%.

Title:DME Changes Effective 07/01/2014 - Blood Glucose Supplies

Run Date:06/12/2014-07/31/2014

PV Types:250 – DMEPOS Providers

Blood Glucose Supplies

OHCA will cover blood glucose (BG) supplies for members who are being treated with insulin to allow a maximum of 100 per month. Coverage for BG supplies for members who are not treated with insulin will be limited to 100 per a 90 days.  In addition, OHCA will cover BG supplies for members who are diagnosed with gestational diabetes, with a maximum allowable of 150 per month. Rates will be adjusted to national competitive bid rates.

If additional supplies are needed, BG supplies are eligible for prior authorization (PA) override if documentation of medical necessity is provided to the Medical Authorization Unit.

Provider Letters-A Provider letter detailing this change is forthcoming.

If you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924

Title:DME Changes Effective 07/01/2014

Run Date:06/12/2014-07/31/2014

PV Types:250 – DMEPOS Providers

Budget Impact – After thoughtful consideration, the agency has determined that an across-the-board rate reduction is required to balance the budget for the upcoming fiscal year.Therefore, a reduction rate of 7.75% will be applied to all DME products.

Manually Priced Items

OHCA will price items that do not have a set max fee rate, also known as manually priced items, by examining the MSRP plus the invoice and paying the lesser of MSRP -30 percent or cost +30 percent for those items.  It will be necessary for the provider to include a copy of the invoice, MSRP and proof of delivery along with the claim when submitting for payment. In addition, the 7.75% Budget Reduction rate reduction will be applied to the claims for manually priced items.

Oxygen

Oxygen equipment and services will require PA effective July 1, 2014.  All claims after July 1, will require a new modifier RR(continuous rental) for oxygen rental. HCPCS codes include E0424, E0431, E0434, E0439, E1390, and E1391.

Provider Letters -Provider letters detailing these changes are forthcoming.

If you have additional questions, please contact DME Director Stan Ruffner at stan.ruffner@okhca.org or 405-522-7924

Title:Medication/Pharmacy PAs

Run Dates:05/30/2014 – 06/30/2014

PV Types:All

Medication/pharmacy prior authorizations (PAs) should NOT be submitted via the provider portal; they will NOT be processed.  To properly submit, please visit www.okhca.org/rx-formsto make your PA request, whether the drug is to be dispensed at a pharmacy or administered by a physician.

Title:Allergen Coding/Payments

Run Dates:05/27/2014 – July 15, 2014

PV Types:All

Effective immediately, OHCA will no longer reimburse for CPT codes 86001 (Allergen specific IgG quantitative or semiquantitative, each allergen) or 86005 (Allergen specific IgE: qualitative, multiallergen screen) in accordance with CMS guidelines. 

Effective 6/1/2014, OHCA will no longer reimburse for CPT codes 95120 (provision of allergenic extract; single injection), 95125 (2 or more injections), 95130 (single stinging insect venom), 95131 (2 stinging insect venoms), 95132 (3 stinging insect venoms), 95133 (4 stinging insect venoms) and 95134 (5 stinging insect venoms) in accordance with CMS guidelines. 

Title:(E0445) Oximeter Rates Increase in July 2014

Run Dates:05/23/2014 – 07/07/2014

PV Types:250 – DMEPOS Providers

The rate for E0445 (Oximeter Device) for measuring blood oxygen levels non-invasively, with rental episodes, will be changed from $120.94 to $193.50 for dates of service after July 1, 2014.  This rate increase includes the oxygen probes (A4606) for use with the Oximeter Device during the rental period. After the rental period is completed, additional probes may be obtained (up to a limit of 4 per month) if prior authorized.

Title: CPT Code 95165 (Preparation of vials for non-venom antigen)

Run Date:05/15/2014 – 07/01/2014

PV Types:All

Effective 06/01/2014, reimbursement for CPT code 95165 (preparation of vials for non-venom antigen) will be limited to ten (10) doses per multi-dose vial, in accordance with CMS guidelines.  If two multi-dose vials are used, provider may bill no more than 20 doses. If less than 10cc aliquot from multi-dose vial is used, provider may bill only for number of 1cc aliquots.

Title: Therapy Management Program

Run Date: 04/30/2014 – 06/15/2014

PV Types: 170-Physical Therapy, 171-Occupational Therapy, 173 & 182-Speech Language Pathology, and, 200- Audiology Providers

Message:

The Oklahoma Health Care Authority (OHCA) continues to implement quality initiatives to support your patient care efforts for SoonerCare and Insure Oklahoma members. In line with this goal, the OHCA is implementing a therapy management program (TMP) for occupational therapy (OT), physical therapy (PT) and speech therapy (ST) in partnership with “MedSolutions and its affiliate Triad Healthcare” (“MedSolutions”), an organization that specializes in managing therapy-related services.  This new process will allow the OHCA to assist our providers and members in obtaining the most appropriate therapy-related service and improve access to high quality, cost effective care in a timely manner.

For all OT, PT and ST services performed on or after July 1, 2014, treating providers will submit prior authorization requests (PARs) to MedSolutions.

PARs can be submitted through a secure internet web portal: www.triadhealthcareinc.com/soonercare, or faxed toll-free: (888) 328-3662. For telephonic inquiries, Triad Healthcare’s toll-free number is: (888) 693-3281.

To help with this transition, MedSolutions will be hosting webinar sessions at various times/dates. These sessions will provide you with all the information required for prior authorization and identify issues that may prevent you from obtaining a timely determination.  For more information about participating in one of these webinars, please visit www.triadhealthcareinc.com/soonercare.

Because MedSolutions has a proven history of providing quality evidenced based review for therapy-related services, OHCA will be accepting their guidelines for use with all prior authorization reviews.  MedSolutions will, however, continue to follow all of the OHCA’s general program requirements and payment/policies, including the current requirements for OT, PT and ST PARs (i.e. OT and PT evaluations may still be performed without prior authorization; however, ST evaluations must be prior authorized prior to rendering services).

MedSolutions is capable of processing all PARs within two (2) business-days; therefore, the 30-day Retro Rule will no longer apply and all OT, PT and ST services must be approved prior to rendering services. The one exception to the exclusion of the 30-Day Retro Rule will be for the month of July 2014.  During this one-month period, after MedSolutions has begun processing therapy-related PARs for the OHCA, the 30-Day Retro Rule will remain in effect, ending on July 31, 2014.

Although school-based services are currently excluded from these changes, please be aware that in the coming months, the above-listed changes will apply to school-based services.  Additional information will be released prior to implementing these changes for school-based services.

Thank you for the quality care that you provide to SoonerCare and Insure Oklahoma members.  If you have questions, please contact the OHCA Medical Authorization Unit at 800.522.0114 or visit our website at www.okhca.org.

Title:  Adult Coverage for Optometry Services

Run Date: 04/23/2014 – 06/04/2014

PV Types: 18 Optometrist, 19 Optician
Spc:  180 Optometrist, 190 Optician, 330 Opthamologist

Adult Coverage for Optometry Services:
Payment can be made for medical services that are reasonable and necessary for the diagnosis and treatment of illness or injury up to the patient's maximum number of allowed office visits per month.

There is no provision for routine eye exams, examinations for the purpose of prescribing glasses or visual aids, determination of refractive state, treatment of refractive errors, or purchase of lenses, frames, or visual aids. Payment is made for treatment of medical or surgical conditions which affect the eyes.

Title: HMO Copays on the New 1500 Claim Forms

Run Date: 04/21/2014 – 06/07/2014

PV Types: All

To assist in the proper payment of HMO co-pay claims, the co-pay amount due should be entered in Block 24F and Block 29 on the “new”1500 form; failing to do so will result in a denial.

On the UB-04 form enter the co-pay amount in Block 47, the TOTALS block and Block 55B.

Please include the EOB or Roster with the corresponding co-pay. HMO co-pays should be filed for fully capitated plans only, not a PPO or Medicare Advantage Plan. These claims must be submitted on paper and mailed to: HP, PO Box 18500, Oklahoma City, OK 73154

OHCA’s Position on ICD-10 Delay

On Tuesday, April 1, 2014, President Obama signed Congressional Bill HR 4302 into law which delays the implementation of ICD-10 by at least one year, to October 1, 2015.  As a result of the delay, the Oklahoma Health Care Authority will continue to accept only ICD-9 codes and deny any ICD-10 codes submitted on a claim until the Secretary of Health and Human Services formally adopts ICD-10 as the new ICD code set standard.

While the implementation of ICD-10 has been delayed, external testing with providers is still a top priority. Before defining the testing schedule however, OHCA is awaiting guidance from CMS regarding the delay. Once the testing schedule is finalized, it will be communicated accordingly.

Title:  OP Surgery Referrals

Run Date: 04/10/2014 -05/29/2014

PV Types: All

In the previous referral system a specialist could use the referral from the SoonerCare Choice Primary Care Provider as approval for OP surgery that a member might need. Because of the unique way our electronic referrals are set in the system this passing along of a referral for OP services is not allowed. If the specialist feels the member needs OP surgery NO referral for the facility will be required. We have modified our system to bypass the referral requirement for OP surgery facility claims. If you have any additional questions please call the OHCA call center at 1-800-522-0114. 

Title: 2014 Provider Workshop – Enid Closing

Run Date: 04/09/2014 – 04/17/2014

PV Types: All

Registration for the April 17, 2014 Spring Workshop for Enid will close on Thursday, April 10th at 5 p.m. Registration for locations in OKC and Tulsa are still available.

Each attendee must register individually.  Please carefully read the class descriptions and recommended audiences before choosing your classes. Register today!

Information and registration is available at:

Class Descriptions: http://www.okhca.org/Classes  

Registration Tool: http://www.okhca.org/Register

To make changes to your registration, please call 405.416.6730 or email HPokxixTraining@hp.com.

Title:  STBS-M (SOON TO BE SOONER MAINTENANCE OF EFFORT)

Run Date: 03/31/2014 – 05/15/2014

PV Types: 
31 Physician
091 OB Nurse Practitioner
181 Maternity
199 OB/GYN Group
214 High Risk Pregnant  Women
316 Family Practitioner
318 General Practitioner
328 Obstetrician/Gynecologist
335 Maternal Fetal Medicine
564 Primary Care Provider

It has come to our attention that Prior Authorization Requests (PARs) for SoonerCare members with the eligibility category of STBS-M have been auto-denying as no active benefits or not in active service.

If you have submitted a PAR for High Risk OB (HROB) services or Diabetic Supplies for an STBS-M member and received an auto denial, please contact us so the PAR can be manually processed.

Providers will need to call the main OHCA call center at 1-800-522-0114 and inform the call center representative that you have a PAR for HROB services or Diabetic Supplies, which auto-denied on an STBS-M member. The representative will then transfer you to the Medical Authorization Unit (MAU), at which time you will be prompted to leave a detailed message.  An MAU representative will research the request and return your call within one (1) business day. 

When prompted to leave a message, please provide the following information.

• Call Tracking Number
• Prior Authorization Number
• Member Name & RID
• Provider Contact Name & Phone Number

We thank you for your patience while the system is updated.

Title:  Electronic Referral Modifications

Run Date: 03/25/2014 – 05/10/2014

PV Types: All

We are making modifications to the electronic referrals in the new SoonerCare Provider Portal. Because it needs additional modifications, both forms of referrals, electronic and paper, will be acceptable. Claims will process based on either form being used.

If the service you are addressing requires a Prior Authorization, this global message does not apply to your circumstance and an electronic referral or SC-10 form is not required for the Prior Authorization review. 

We will let you know when only electronic referrals are to be used to request services.

Title:  2014 Spring Provider Training Workshop

Run Date: 03/21/2014-05/16/2014

PV Types: All

PLEASE JOIN US FOR THE 2014 SPRING PROVIDER TRAINING WORKSHOP!
You and your staff are encouraged to attend the Spring 2014 SoonerCare Provider Training Workshops hosted by the Oklahoma Health Care Authority (OHCA) and HP Enterprise Services. Classes offered will be Electronic Health Records (EHR), SoonerCare audits, Adjustments/Third Party Liability (TPL), Durable Medical Equipment (DME), and a class that will highlight the key features utilized on the new provider portal. These workshops will be held in 4 locations, beginning April 10th.

Register today!

Information and registration is available at: 

• http://www.okhca.org/register 
• http://www.okhca.org/classes

Durant, OK will be the first stop on April 10 followed by: Enid, April 17; Tulsa, April 30-May 1; and, conclude in Oklahoma City, May 14–15.

Title: REMINDER: New Paper 1500 Claim Forms

Run Dates: 12/20/2013 – 03/31/2014 extended through 04/30/2014

PV Types: All

OHCA will be able to accept the new paper 1500 forms starting January 6, 2014. We will be able to process both claim forms through March 31, 2014. Effective April 1, 2014 all 1500 claims filed must be on the new 1500 form regardless of the date of service.

Title:  Submission of Dental PA’s

Run Date:  03/06/2014 – 04/21/2014

PV Type:  27 – Dentist
   Spc:  86 – Dental Clinic
   271 – General Dentistry
   272 – Oral Surgeon
   273 – Orthodontist
   274 – Pediatric Dentist

MESSAGE:

For all dental providers:

When submitting a Dental Prior Authorization request, we are unable to accept zip files.  Only JPEG, TIF, and PDF files are allowed. We appreciate your patience cooperation in this matter!

Title:  CM II Training

Run Date: 03/05/2014 – 04/01/2014

Pv TYPES: 11

Children's Certificate in Psychiatric Rehabilitation In-Person Course:

Resiliency and psychiatric rehabilitation services are invaluable to children and their families. Increase your abilities and knowledge as a youth services practitioner by earning your Certificate in Children’s Psychiatric Rehabilitation (20 contact hours).

Children's Certificate in Psychiatric Rehabilitation - Oklahoma City, OK

March 10-12, 2014

Best Western Saddleback Inn and Conference Center, 4300 Southwest Third Street, Oklahoma City, OK 73108

Members: $495; Non-Members: $595 (Join Today)

http://www.uspra.org/certification/childrens-certificate

Title: CPT Code 92250

RUN DATES: 03/05/2014 – 04/20/2014

PV Types: All

Effective 3/1/2014, CPT 92250 (fundus photography) is not covered for routine screening or typical refractive error diagnosis and is limited to one service annually.

Title:  CPT Codes 65093 & 65105

RUN DATES: 02/27/2014 – 04/15/2014

PV Types: All

Effective 1/1/2014, CPT 65093 (Evisceration of Ocular contents, with implant) and CPT 65105 (Enucleation of eye, with implant, muscles attached to implant) age restrictions have changed to 0-999 years.

Title: Clarification – Submitting PAs via the Provider Portal

Run Date: 02/26/2014 – 04/15/2014

PV TYPES: All

Clarification Regarding Prior Authorizations Requests (PARs) via the Provider Portal:

We have become aware that during recent Provider Training addressing the new Provider Portal, confusion was created regarding the PA Process handled by the Medical Authorization Unit (MAU).

The process for submitting a PAR to the MAU has not changed. We require the same information to be submitted, regardless of whether the request is submitted via fax or using the Provider Portal.

Required documentation:
If you are entering a PAR via the Provider Portal, you will still need to submit the following:
1. HCA-12A or a copy of the on-line PA Authorization screen or you may save a copy of this screen as a WORD document and attach it to the PA when you are uploading your documentation (The MAU staff are not able to view this information in our PA Workflow System).

For High Risk OB requests, the completed CH-17 form is still required.

Therapy PARs: The rendering/servicing provider should be the individual provider ID# or NPI of the therapist who will provide the services. Claims will not pay if a group ID is listed, as the individual licensed professional must file the claim.

2. The MAU requires a script or order from the treating provider for ALL PARs.

3. CMN (Certificate of Medical Necessity): If required, please see the section regarding Forms.

4. Required documentation: Please refer to the individual sections on the OHCA Public Webpage for pertinent information (www.okhca.org, Providers, Medical Authorization Unit, scroll to the necessary section, click to view information).

5. Photos can be scanned and upload in the same manner as uploading documents. Unfortunately, videos still require delivery via mail service.

We encourage you to use the Provider Portal to submit your PARs with the uploaded documents, as this reduces the potential for problems we have experienced in the past with providers faxing documents, especially legibility issues. For further information, please contact the MAU @ (800) 522-0114.

Title: 2014 EHR Documents Email Available

Run Date: 02/25/2014 – 06/30/2014

PV Types: 01- Hospital, 31- Physicians, 52- State Employed Physicians, 09- Advance Practice Nurse, 27- Dentist, 10– Mid-level Practitioners

OHCA is now accepting email for patient volume documentation files at EHRDocuments@okhca.org. When sending the email, please include the provider’s name, NPI and ATN from the fax coversheet in the subject line. All emails should be sent securely when sending PHI. Please note the email is only to be used for patient volume documentation, you will still need to fax in the fax coversheet, signature page, vendor letter and meaningful use report to the fax number provided on the coversheet.

Reminder:  The end date to submit your 2013 reporting year attestations is March 31st, 2014.

Title: Electronic Referral System Available Through the Portal

Run Date: 02/18/2014 – 04/03/2014

PV Types: All

As we are moving from paper referrals to the electronic referral system available through the portal, please keep in mind that the new system was only designed to replace the SC-10 form (paper referrals). The new referral will allow OHCA to track specialty utilization and allow claims to process. You will need to continue to send  additional information that was requested from the specialist. This includes contact information for the members, face sheets, office notes etc. for continuum of care, for these members. Also, please note when submitting a new referral from the new provider portal, PCP’s should confirm the related NPI and address of the specific specialist that is being referred to.  OHCA and HP are still reviewing ways to improve this new process. In conclusion, at this time paper referrals are still accepted through March 31st 2014.  

Title: 2014 Spring School-Based Training Schedule

Run Date: 02/10/2014 – 04/04/2014 PV Types: 12 Spc: 120

School-Based Training is scheduled for the following dates and times.

March 5, 2014 – McAlester (10:00 am to 12:00pm)
March 6, 2014 – Stillwater (10:00am to 12:00pm)
March 10, 2014–  Oklahoma City (10:00am to 12:00pm)
April 1, 2014– Poteau (1:00pm to 3:00pm)

Register for training through OHCA website at
http://www.okhca.org/schoolbased

Title:  Claims Submissions Extension
Run Date: 02/05/2014 – 03/20/2014
PV Type:  All

Please be advised that due to issues regarding the new OHCA provider portal, we will allow claims submissions up to 12:00 PM on Thursday 02/06/2014.  There will be no impact to the payment date. 

Thank you for your support as we continue to work through the issues related to the provider portal

Title: School Based Fee Schedule

Run Date: 01/30/2014 – 03/15/2014

PV Types: 12  - School Corp Spc:  120 – School Corp

Effective January 1, 2014 the School Based Fee Schedule has changed in regards to speech language evaluations

Review the updated fee-schedule on the OHCA website at

/content/sok-wcm/en/okhca/providers/school-based-services

Title: Provider Portal / Claims Submissions

Run Date: 01/28/2014 – 03/15/2014

PV Types: All

Please be advised that due to issues regarding new OHCA provider portal, we will allow claims submissions up to 5:00 PM on Friday 01/31/2014.  There will be no impact to the payment date.  Thank you for your support as we continue to work through the issues related to the provider portal.

Title: 2014 EHR Attestations Now Available

Run Date: 01/16/2014 – 04/30/2014

PV Types: 01- Hospital
31- Physicians
52- State Employed Physicians
09- Advance Practice Nurse
27- Dentist
10– Mid-level Practitioners

SoonerCare is now accepting Stage 2 attestations. CMS published a final rule that specifies the Stage 2 criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to continue to participate in the Medicaid Electronic Health Record (EHR) Incentive Programs. If you have not participated in the Medicaid EHR Incentive Programs previously, or if you have never achieved meaningful use under the Stage 1 criteria, please visit www.okhca.org/ehr-incentive or contact us at 405-522-7EHR for more information about how to take part in the program.

Title: BH Portal Info/Required Security Enhancements

Run Date: 01/16/2014 – 03/01/2014

PV Type: 08, 11, 53 Spc: 110, 111, 112, 115, 121, 193, 585, 535, 536

The provider portal will go live on January 24, 2014, our legal team as well as 45 CFR § 164.304, 164.306 and 164.312 of the Federal Health Insurance Portability and Accountability Act (HIPPA) requires security enhancements that will require all providers and submitters to manually log in and verify certain attributes to upload and download files. Some software on the market had created a script for auto populating security data to upload and download, this practice will no longer be allowed and was never approved by OHCA.  In fact, OHCA advises that for your protection and ours, that you use each of the security functions to insure that PHI and your billing files are kept as secure as possible.

Title: Webinars: New Portal Training

Run Dates: 01/15/2014 – 02/01/2014

PV Types: All

OHCA and HP Enterprise Services are excited to announce Webinar training sessions. Webinars will address topics for certain provider types that are relevant and timely for you and your staff. These trainings will be hosted by HPES through HP Virtual Rooms and will last approximately one hour.

Register now for these great interactive sessions! The 1500 and UB04 classes will be your last opportunity for training, before the new site goes live!

Classes offered: 

Thursday, January 16 - 2:30 p.m. – 1500 Professional Claim - New Portal (1/16/14)  - Click To Register

Recommended Audience: All SoonerCare providers, their staff, and billing entities that bill on a 1500 professional claim form.

Description: This class will introduce the new SoonerCare provider portal to providers and entities who, currently, submit 1500 professional claims to the Oklahoma Health Care Authority. This class will cover new and enhanced processes for claim submission, viewing electronic remits, payment history and many additional features.

Thursday, January 23 - 2:30 p.m. – UB-04 Institutional - New Portal (1/23/14)  - Click To Register

Recommended Audience: This is recommended to all SoonerCare providers, their staff, and billing entities that bill on a UB-04 claim form.

Description: This class will introduce the new SoonerCare provider portal to providers and entities who, currently, submit UB-04 claims to the Oklahoma Health Care Authority. This class will cover new and enhanced processes for institutional UB-04claim submission, and many additional features.

Thursday, January 30 - 2:30 p.m. – Referral - New Portal (1/30/14)  - Click To Register  

Recommended Audience: All SoonerCare Choice MH providers are strongly encouraged to attend as well as specialty providers whose services require a SoonerCare referral.

Description: This class will introduce providers to the new required electronic referral process within the new SoonerCare provider portal. It will cover how Medical Home (MH) providers will initiate specialty referrals and how specialty providers will receive these referrals. Medical Home providers are strongly encouraged to attend this class as this process replaces the paper referral (SC-10) process beginning this winter.

Title:  New 1500 Claim Form Submissions

Run Date: 01/09/2014 – 02/24/2014

PV Types: All

OHCA is returning many 1500 [paper] Claim Forms to providers. The [new] 1500 Claim Forms are being printed/submitted with the [old] 1500 Form locators information; therefore, the information does not line up and cannot be processed.

Please ensure that all information is printed in the correct areas of the new 1500 Claim Form (02-12) to allow successful processing.

Title: Exemption for Waiver Programs for Ordering/Referring Provider NPI Requirement

Run Dates: 01/07/2014 – 01/31/2014

PV Types:  250 – DME/Medical Supply Dealers

Unfortunately, OHCA systems have not been updated to agree with the exemption for Ordering/Referring NPI Requirement as of January 6, 2014 previously reported by OHCA and Waiver Advantage.

If your claim has “SUSPENDED” as the denial description; no further action is required by the provider.  OHCA will reprocess claims in this category once the system fix is implemented.

If your denial is anything other than “SUSPENDED”; it will be necessary for you to reprocess the claim after you are notified of the system fix.

OHCA systems staff is working to correct this system edit and you will be notified as soon as it is implemented.