Certification

Certification is required within three working days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures, or within one day following emergency/urgent services. To request certification, the provider must contact the certification administrator.

If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10% penalty is applied. The member is not responsible for this 10% penalty. If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied.

When using a non-Network provider, the member is responsible for paying the 10% penalty and for any services that are not deemed medically necessary according to HealthChoice guidelines.

For a more detailed list of the codes that require certification, please refer to the HealthChoice Certification Code List found at https://gateway.sib.ok.gov/feeschedule/Login.aspx. For more information or to request certification for these services, contact HCMU at 405-717-8879, or at toll-free 800-543-6044 ext.8879. For TDD call 405-949-2281, or toll-free at 866-447-0436. Fax: 405-949-5459 or 405-949-5501.

1. Chiropractic Therapy.
   • ​Required only after initial 20 visits per calendar year.
   • Visits are limited to 60 total per calendar year (some exceptions apply).
2. Drugs and Medical Injectable.
   • Required for specified medications covered under the HealthChoice medical plan; this is not inclusive of requirements under the HealthChoice Pharmacy Benefits Administrator.
   • Required for Botox Injections that are non-cosmetic and rendered in the Physician’s Office.
3. Durable Medical Equipment.
4. Enteral Feeding.
5. Foot Orthotics.
6. Genetic Testing.
7. Glucose Monitors: Continuous.
8. Hearing Aids.
9. Home Health Care (Visits limited to 100 per calendar year).
10. Home Intravenous (IV) Therapy (not subject to Home Health Care limits).
11. Hyperbaric Oxygen Therapy (Outpatient).
12. Mental Health Treatment.
    • Required for Outpatient services after initial 20 visits per calendar year.
    • Required initially for Intensive Outpatient Therapy services.
    • Required initially for TMS treatment.
    • Required initially for esketamine.
    • Required initially for Applied Behavior Analysis services.
13. Occupational Therapy (Outpatient).
    • Required after initial 20 visits per calendar year.
14. Oral Splints and Appliances (some exceptions apply).
15. Oral Surgery (Inpatient/Outpatient).
16. Oxygen.
17. Physical Medicine/Physical Therapy (Outpatient).
    • Required only after initial 20 visits per calendar year.
    • Visits are limited to 60 total per calendar year (some exceptions apply).
18. Prostheses and Orthopedic Appliances (some exceptions apply).
19. Speech Therapy.
    • Required only for age seventeen (17) years and younger.
    • Visits limited to 60 total per calendar year (some exceptions apply).
20. Substance Use Disorder Treatment.
    • Required for Outpatient services after initial 20 visits per calendar year.
    • Required initially for Intensive Outpatient Therapy services.
21. Unlisted and Not Otherwise Specified – required for specified codes.

HealthChoice requires supporting clinical documentation to be submitted for all unlisted or NOS codes.  

For a more detailed list of the codes that require certification, please refer to the HealthChoice Certification Code List found https://gateway.sib.ok.gov/feeschedule/Login.aspx. For more information or to request certification for these services, contact AHH toll-free at 800-323-4314, option 2. TDD users call toll-free 800-545-8279. Fax: 855-532-6780.

1. Bariatric Surgery (Eligibility criteria also required).
2. Exhaustion of Medicare Lifetime Reserve Days.
   • Required for the additional 365 lifetime reserve days for hospitalization.
3. HealthChoice is 2nd or 3rd Payer.
   • Required only after Medicare benefits are exhausted.
4. Inpatient Admissions.
5. Maternity Care.
   • Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery.
6. Mental Health Treatment (inpatient, residential, partial hospital).
7. Myocardial PET Scan.
8. Observation Stays =/> 48 hours.
9. Outpatient Surgical Procedures:
   • Blepharoplasty.
   • Mammoplasty (including reduction, removal of implants and symmetry).
   • Correction of lid retraction.
   • Panniculectomy.
   • Rhinoplasty.
   • Septoplasty.
   • Varicose vein surgeries and procedures:
     • Including Sclerotherapy.
   • Sleep Apnea related surgeries, limited to:
     • Radiofrequency ablation (coblation, somnoplasty).
     • Uvulopalatopharyngoplasty (UPPP), including laser-assisted procedure.
10. Prophylactic and Gynecomastia Mastectomies.
11. Proton Beam Radiation Therapy.
12. Skilled Nursing Facility.
13. Spinal Surgical Procedures:
    • Cervical.
    • Lumbar.
    • Thoracic.
14. Spinal Cord Stimulator Placement and Revision.
15. Substance Use Disorder Treatment (inpatient, residential, partial hospital).
16. Transplants.
17. Unlisted and Not Otherwise Specified – required for specified codes.

HealthChoice requires supporting clinical documentation to be submitted for all unlisted or NOS codes.

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To request certification, print a copy of the applicable certification form. Please complete the form and fax it directly to the HealthChoice Health Care Management Unit. To access the following certification forms, follow the links below:

• Applied Behavioral Analysis Request
  
• BRCA Request
• Chiropractic Treatment Request
• Durable Medical Equipment Referral Information
• Esketamine Request
• Home Health Request
• Hospice Request
• Infusion Therapy Request
• Mental Health Request
• Occupational Therapy Request
• Oral Surgery Request
• Physical Therapy Request
• Speech Therapy Request
  
• Substance Use Disorder Treatment Request
• TMD/TMJ Request
• Transcranial Magnetic Stimulation Request
• Treatment/Medication Request - Do not use this form for medications being picked up at a pharmacy.

SilverScript Plan Members 
To request a Part D prior authorization, contact CVS/caremark toll-free at 855-344-0930.

Current employees, Pre-Medicare Former Employees and Without Part D Plan Members 
To request a prior authorization, contact CVS/caremark toll-free at 800-294-5979.

Certification Administrator Request Form
Use this form to certify diagnostic imaging services, specific outpatient surgeries and inpatient health care as specified in the Provider Network contracts and identified in the Provider Manual. Penalties are applicable for services that are not certified.