Fee Schedule Updates
Future fee schedule updates for services provided by HealthChoice network providers are scheduled for:
Comp – Comprehensive
A/C/D – Adds, changes, deletes and other necessary updates
The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban/rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area. As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. When these modifications occur, EGID reviews them as quickly as possible and makes any necessary updates. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary.
Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1, based on the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the ZIP code of its physical location which is included in the U.S. Census Bureau’s metropolitan core-based statistical area. On Jan. 1, the urban/rural indicator will be updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals.
For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area.
Inpatient and outpatient tier designations are defined as:
- Tier 1 – Network urban facilities with greater than 300 beds.
- Tier 2 – All other urban and non-network facilities.
- Tier 3 – Critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
- Tier 4 – All other network rural facilities.
Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the program will become fully phased in during the next quarterly update.
Fee schedule updates are reported in each quarterly issue of the Network News newsletter. If you need specific codes and allowable fees affected by these updates, please visit our fee schedule website and view or download the latest fee schedule addendum. The fee schedule has not been publicly disclosed and is deemed confidential pursuant to 51 O.S. and should not be disseminated, distributed or copied to persons not authorized to receive the information. If you have questions or need additional information, please contact network management.
The following terms are used in the fee schedule:
- BR: by report.
- BR1: 60% of billed charges for Tiers 1 and 2; 70% of billed charges for Tiers 3 and 4.
- BR2: 30% of billed charges for Tiers 1 and 2; 35% of billed charges for Tiers 3 and 4.
- BR3: 0% of billed charges for Tiers 1, 2, 3 and 4.
- Health: submit to health plan.
- I: incidental.
- IC: individual consideration.
- NC: non-covered.
- NOC: non-classified drugs.
- Per Diem: per diem rate.
- RX: submit to pharmacy administrator.
- TM: use of time.
- Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee.
- Anesthesia conversion factors (2020).
- $59 CRNA.
- $62 M.D./D.O.
- Anesthesia assistant is 50% of allowable fee.