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Provider Manual

HealthChoice is a managed health care program providing comprehensive health and dental benefits to over 186,000 state, education and local government employees, former employees, survivors and their covered dependents.

HealthChoice is administered by the Office of Management and Enterprise Services Employees Group Insurance Division (EGID). The HealthChoice plans are a partnership between providers, members and EGID in the delivery of health and dental care services and products that helps control costs, assists in the provision of high-quality health and dental care, and enhances provider-patient relationships. The HealthChoice benefit structure offers financial incentives to encourage plan members to utilize HealthChoice network providers.

EGID provides health and dental care benefits in accordance with the provisions of Oklahoma Statutes, (74 O.S. 2012, §§ 1301, et seq.). The information provided in this manual is a summary of the benefits, conditions, limitations and exclusions of the HealthChoice High, High Alternative, Basic and Basic Alternative health plans, High Deductible Health Plan (HDHP) and the HealthChoice Dental Plan. It should not be considered an all-inclusive listing.

While the HealthChoice Network Provider Manual is a summary only and is not intended to be all-inclusive, its contents should offer providers and their staff vital information regarding the most important aspects of the provider network.

Plan benefits are subject to conditions, limitations and exclusions described and located in Oklahoma Statutes, Administrative Rules, and Administrative Procedures adopted by the plan administrator. You can obtain a copy of the official rules from the office of the Oklahoma Secretary of State. An unofficial copy of the Administrative Rules is available on this website. 

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Advanced Communication Engine

Effective Jan. 1, 2018, HealthChoice adopted industry standard claim editing guidelines, a combination of CMS, CCI and McKesson claim editing criteria, which have been evaluated for implementation based on plan experience.

To ensure our network providers have the best possible experience with our organization, we launched our new Advanced Communication Engine system. ACE is available to all direct submitters as well as those who transmit claims via clearinghouses or billing services. ACE Edits will appear on claim rejection reports (277CA). 

  • ACE alerts you to deny certain claims through claim acknowledgement transaction reports with clear instructions on how to fix the error and access the supporting documentation that triggered the alert.
  • Claims failing the pre-adjudication editing process are not forwarded to our claims adjudication system.
  • ACE integrates into your current electronic data interchange (EDI) workflow so you can modify claims before submission.
  • After you have reviewed the ACE Edits, if you choose not to change the claim, you can resubmit in its original format and it will pass directly into our claims adjudication system for processing.

ACE does not require any downloads or changes in your current EDI work stream, and it’s available to you at no cost. Help improve clean claim rates and increase collections with actionable edit intelligence.

Providers should work with their existing clearinghouse or billing service to stress the importance of receiving a full 277CA claim submission report to include the ACE Edits. 

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Jan. 1, 2019, EGID will implement a change to their ambulance reimbursement methodology as discussed at the public hearing on Oct. 16, 2018. The change will be effective Jan. 1, 2019, for providers of ambulance services to HealthChoice and the Department of Corrections. A fee schedule will be adopted for ambulance HCPCS billing codes. The fee schedule will be based on the rates published by the Centers for Medicare & Medicaid Services with a multiple applied. The fee schedule effective Jan. 1, 2019, will be based on the CMS CY 2019 Oklahoma Medicare rates, which have not yet been released. A pro forma fee schedule modeled using the CMS CY 2018 Oklahoma Medicare rates would be as follows: 

HCPCS Description EGID Modeled Fees Based on CMS CY 2018 for Oklahoma
A0425 GROUND MILEAGE PER STATUTE MILE 18.00
A0426 AMB SERVICE ALS NONEMERGENCY TRANSPORT LEVEL 1 705.60
A0427 AMB SERVICE ALS EMERGENCY TRANSPORT LEVEL 1 1,300.00
A0428 AMBULANCE SERVICE BLS NONEMERGENCY TRANSPORT 588.01
A0429 AMBULANCE SERVICE BLS EMERGENCY TRANSPORT 940.80
A0430 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY 20,544.80
A0431 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY 23,886.42
A0432 PARAMED INTRCPT RURL AMB NO BILL 3 PARTY PAYER NC
A0433 ADVANCED LIFE SUPPORT LEVEL 2 1,617.03
A0434 SPECIALTY CARE TRANSPORT 1,911.03
A0435 FIXED WING AIR MILEAGE PER STATUTE MILE 61.66
A0436 ROTARY WING AIR MILEAGE PER STATUTE MILE 164.54

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HealthChoice encourages ambulatory surgery centers to bill facility charges on a form UB-04 or through 835i electronic claims. However, HealthChoice will accept facility charges when billed on a CMS 1500 form as outlined below.

When an ASC bills both the professional and ambulatory surgery center charges on a CMS 1500 form, it can be difficult to distinguish between the two.

To ensure that ASC claims and professional claims are paid as separate services and at the correct rates, providers should follow these guidelines when billing a CMS 1500 form:  

  • Ensure that the ASC claim does not include the rendering provider’s Type 1 NPI. On a CMS 1500 form, this information is often included in field 24. However, for ASC claims, you should leave field 24J blank.
  • Include all facility information in box 33 and the ASC’s NPI in field 33a; this is the billing provider information.
  • Add an SG modifier to the first modifier field for service codes. The SG modifier distinguishes the claim as an ASC claim (facility claim).
  • Use the place of service indicator for an ASC; this is place of service 24.

For questions about ASC facility billing, contact the medical and dental claims administrator at toll-free 800-323-4314.

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HealthChoice covers specific bariatric surgical procedures subject to certification and clinical criteria and guidelines set forth by the Certification Administrator. These procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP) Comprehensive Center of Excellence contracted with HealthChoice as a network facility provider. 

The benefit also includes related pre-operative and workup services. All covered procedures and related services are subject to plan provisions including member liability for copay, coinsurance and deductible amounts. The covered procedures are: 

  • Sleeve.
  • Bypass.
  • Duodenal switch.
  • Revision and conversions of a sleeve, bypass or duodenal switch procedure when medically necessary. The initial bariatric surgical procedure must have been performed according to one of the following:
    • As part of the HealthChoice bariatric surgery pilot program, dates of service Jan. 1, 2013, thru Dec. 31, 2017.
    • Under the HealthChoice plans on or after Jan. 1, 2017.

The bundled allowed amount includes the facility, surgeon, assistant surgeon, anesthesiology, laboratory, pathology, radiology and other related services when those services are rendered on the same date or during the hospital confinement. These services are subject to bundled reimbursement methodology and plan provisions including member liability for copay, coinsurance and deductible amounts. 

To be eligible for the benefit, participants must be a HealthChoice member, spouse or child, age 18 or older, with no other primary coverage. 

  • The participant must be covered under a HealthChoice health plan for 12 consecutive months prior to bariatric surgery regardless if the member has been eligible under other plans offered by EGID.
  • The participant will be encouraged to continue health coverage with HealthChoice for 24 months post-surgery.
  • The participant must meet specific criteria, which includes, but is not limited to, severity of obesity, reliable participation in preoperative weight-loss program that is multidisciplinary, and expectation of adherence to postoperative care.

The following services are not covered: 

  • Band and band revisions.
  • Bariatric surgical services obtained from any facility that is not a HealthChoice bariatric network provider.
  • Revisions to bariatric surgical procedures originally obtained during a time when the individual was not covered by HealthChoice.
  • Revisions to bariatric surgical procedures originally obtained from a facility that was not a HealthChoice bariatric network provider.
  • Related workup and postoperative services billed with a diagnosis code of obesity (ICD-10 code E66).

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Title 36 O.S. 2011, Section 6060.21, Health Coverage with Individuals with Autism, mandates coverage for applied behavior analysis. HealthChoice covers these services when performed by a registered behavior technician (RBT), board-certified behavioral analyst (BCBA), board-certified assistant behavioral analyst (BCaBA) or doctoral-level psychologist.

Please note any applied behavioral analysis services performed in a school setting (POS 03) are not eligible for reimbursement.

The maximum benefit for applied behavior analysis is 25 hours per week and no more than $25,000 per calendar year. A current treatment plan from the BCBA or BCaBA, which includes a prescription from the treating physician, is required upon receipt of the first claim each rolling year. 

All plan policies, provisions, deductible, copay and coinsurance apply. 

For additional information on coverage of autism spectrum disorders, call the medical claims administrator toll-free at 800-323-4314. TTY users call 711 or toll-free 800-545-8279. 

Certification is a review process used to determine if certain services are medically necessary according to HealthChoice guidelines. Certification is performed by either the HealthChoice certification administrator or by the HealthChoice Health Care Management Unit (HCMU), depending on the type of service.

The provider must obtain certification under certain situations, including when the member or the member’s covered dependents:  

  • Are admitted to a hospital or are advised to enter a hospital;
  • Require certain surgical procedures that are performed in an outpatient facility;
  • Require certain diagnostic imaging procedures; or
  • Have HealthChoice as the second or third carrier.

Guidelines

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 percent 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 percent penalty and for any services that are not deemed medically necessary according to HealthChoice guidelines.

The below services require certification through the HealthChoice Health Care Management Unit. 

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.  

 

The below services require certification through the HealthChoice Certification Administrator. 

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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HealthChoice is partnered with ECHO Health, a payment disbursement service for claim payment and electronic remittance advices (ERA). ECHO Health is an industry leader in payment administration.

HealthChoice providers will receive the following EFT/ERA services at no cost:

  • EFT payments.
  • Download ERAs from www.providerpayments.com.
  • ERA routing to your designated clearinghouse.
    • To receive your ERA through your clearinghouse, refer to information below.
  • Daily payment disbursement.
  • Email notifications of payment (set up through ECHO Health).

HealthChoice encourages providers and facilities to reach out to ECHO Health customer service at toll-free 888-834-3511 if your organization:

  • Is newly contracted with HealthChoice. 
  • Does not currently have access to ECHO Health’s provider portal, www.providerpayments.com.
  • Would like to automate the ERA delivery through your preferred clearinghouse partner.

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Claims can be submitted by paper, HIPAA 837 electronic claims submission or through the provider portal at healthchoiceconnect.com

Electronic Claims Submission 

Providers can submit claims electronically utilizing clearinghouses in conjunction with the electronic claims payer ID 71064.

All electronic transactions must conform to HIPAA 5010 standards. Claims that are not in compliance are either rejected or denied.

If you consistently have issues with the claims that do not process quickly, please verify the format your intermediary or clearinghouse uses to submit your claims. Make sure they are filing your claims electronically and not on paper; it takes much longer to process paper claims.

When you submit a claim electronically and then submit a duplicate paper claim, it can significantly slow down your payment. If you submit a claim and need to verify payment, please contact our medical and dental claims administrator or log in to the provider portal to check the status. Resubmit a claim only if it is not already on file. When the same claim is submitted multiple times, each additional claim can deny as a duplicate and further delay the adjudication process.

Direct Data Entry

Providers have the ability to submit individual claims without any intermediary software through the direct data entry feature on Availity. The direct data entry feature allows providers to submit individual medical, dental or hospital claims directly to the claims administrator. The provider receives an immediate response regarding the status of the claim with real time responses indicating if the claim has been paid, denied or suspended. The direct data entry of claims feature can be accessed through the provider portal.

DentalXChange is a free service for dental providers, provided by HealthChoice, for the direct data entry of dental claims. Dental providers can register for this service through DentalXChange.

Paper Claims Submission

Under the terms of the HealthChoice Network Provider contract, HealthChoice network providers are required to file claims for HealthChoice members. Providers should submit claims on forms acceptable to HealthChoice within 365 days of providing the medical services, utilizing appropriate ICD-10 coding methodology. 

Use the current claim form to expedite claims processing. Acceptable claim forms are: 

  • CMS 1500.
  • UB-04.
  • ADA 2012.

Regardless of the claim form utilized, claims are processed according to the appropriate fee schedule. New claims, medical records, correspondence and corrected claims should be submitted to: 

HealthChoice 
P.O. Box 99011 
Lubbock, TX 79490-9011

Please do not send medical records unless instructed to do so.

For faster service, and to save time and expense, dental providers should not send X-rays or molds with their claims or dental predeterminations unless request to do so. 

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HealthChoice utilizes combined payments for all providers. Under the combined payments feature, all payments for a given day are combined into a single remittance advice for a single provider. Combined payments facilitate the processing of claim payments for providers. If you have questions or you need more information, contact the medical and dental claims administrator for assistance.

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Under the terms of the network provider contract, the coordination of benefits rules are subject to change. HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Following is a brief description of the rules that apply: 

  • Allowable expense is a health care expense, including deductibles, coinsurance and copayments, covered at least in part by any plan covering the person. An expense not covered by any plan covering the person is not an allowable expense. Any expense that a provider is prohibited (by law or by contract) from charging a covered person is not an allowable expense.
  • The benefits paid by medical and dental plans will equal no more than the allowable expense.
  • The amount of any benefit reduction by the primary plan because a covered person has failed to comply with the plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and failing to use the primary plan’s preferred provider arrangements.
  • HealthChoice shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
  • There is no “lesser of” calculation involving the primary carrier and HealthChoice allowable amounts or of what HealthChoice would pay in the absence of other health care coverage. If the primary carrier paid zero on the entire claim, then HealthChoice will pay its normal benefits (unless bullet 3 applies).
  • The only amount updated in the out-of-pocket max bucket is the true OOP the member has to pay, excluding charges for non-covered services, balance billing charges from non-network providers and amounts paid by third parties.
  • HealthChoice requires verification of other insurance on a rolling 12-month basis.

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HealthChoice allows the billed charge or allowed amount, whichever is less, of the set copay up to the out-of-pocket maximum. All provider remittance advices and 835 transactions will reflect the accurate copay amount. (Effective Jan. 1, 2017)

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A dental predetermination is an itemization of proposed dental charges and their reimbursements before dental services are performed. It should not be confused with certification. A predetermination is not required, but is recommended when the dental treatment plan proposed by the provider is expected to exceed $200. A predetermination also shows the financial liability of the member. It should be identified as a predetermination and submitted in the same manner as a standard paper dental claim or HIPAA 837 electronic claims submission.

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CPT code 21248 is for partial restorations using implants involving less than half of the arch, while 21249 is for complete restorations involving more than half of the arch. Do not report these codes for each implant. Only report one instance of the applicable code, and report the number of implants placed in the “units” column.

Certification is required.

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HealthChoice has implemented a benefit for coverage of the Centers for Disease Control and Prevention (CDC)-recognized National Diabetes Prevention Programs (DPPs) and is contracting with provider organizations in Oklahoma that have achieved full CDC recognition. The CDC National DPP is a lifestyle change program that offers evidence-based, cost-effective interventions that help prevent type 2 diabetes. The program is intended to create behavioral changes to improve healthy eating, increase physical activity and manage stress. 

Participation in the program is offered as a preventive service. HealthChoice covers qualifying preventive care services at 100% of allowable fees for a qualifying code when rendered by a participating network provider. There are no copays, deductibles or coinsurance applied under this benefit.  

All HealthChoice participants who meet DPP eligibility as established by a participating DPP provider are eligible for one year in the program. Members who successfully meet the year one performance goal will be eligible to continue participation in ongoing maintenance sessions through year two.  

To locate a network DPP, visit the HealthChoice Provider Search site at https://gateway.sib.ok.gov/providersearch/SpecialtySearch.aspx#grid and search by specialty. 

For additional information, call EGID Network Management at 405-717-8790 or toll-free 844-804-2642. 

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HealthChoice requires providers to indicate the name of the drug being administered on claim submissions, even if reimbursement is not being requested for the drug. HealthChoice will not pay for the administration charge unless the drug being administered is covered and medically necessary. If the provider is billing drug-related revenue, HCPCS or CPT codes, the claim must indicate the drug’s national drug code (NDC), quantity and unit of measure. 

This policy applies to all professional and hospital outpatient claims containing drug-related revenue, HCPCS or CPT codes which must be billed with the NDC indicated on the container from which the medication was administered. The NDC is not required for G codes and P codes, routine childhood and adult immunization drug codes. The NDC must be 11 digits (5 digits-4 digits-2 digits) in order for it to be accepted; however, there are times when the NDC on the container does not contain 11 digits. In this case, you will add preceding zeroes to the section of the NDC that does not follow the 5-4-2 format. 

The drug-related revenue, HCPCS or CPT codes will need to indicate the number of units for reimbursement purposes as defined in the description of the code being billed. You must include the NDC units to report the units being administered. Both are required on the claim for accurate reimbursement. To bill NDC units, the unit of measurement and the quantity (including decimals) are required. Acceptable units of measurement are GR for gram, ML for milliliter, UN for unit, and international unit F2. For example, if the provider administers two .75 milliliter vials, you would report ML1.5. 

You may have multiple NDCs when you administer multiple drug strengths to a patient or when a drug is comprised of more than one ingredient. Submit each NDC number as a separate claim line with the appropriate revenue, HCPCS or CPT drug code. There are standard billing modifiers to use when there is more than one NDC for a service code. For paper claims, use KP (the first drug of a multiple drug formulation) and KQ (the second or subsequent drug of a multiple drug formulation). For electronic claims, report compound drugs by repeating the LIN and CPT segments in loop 2410. If the box for the drugs contains more than one medication, use the NDC number found on the box. However, if the box for the drugs contains multiple vials of the same medication, use the NDC number found on the vial. There are exceptions when drug manufacturers don’t provide pricing at the individual vial level. Generally, only NDC numbers with available pricing are considered valid. In these instances, you should bill using the NDC information from the outside packaging and include the correct units administered. 

CMS 1500 form: 

  • Enter the NDC information in field 24. There are six service lines in field 24 with shaded areas.
  • Place the NDC information in the line’s top shaded part.
  • Enter any supplemental NDC information in the following order:
    • N4 qualifier.
    • 11-digit NDC code.
    • Add one space.
    • Two-character unit of measurement and quantity.

UB-04 form: 

  • Field 42: Include the appropriate revenue code.
  • Field 43: Include the 11-digit NDC code, unit of measurement and quantity.
  • Field 44: Include the HCPCS code if required.

EDI requirements for professional (837p) and institutional (837i) claims: 

Loop Segment Element name Information  
2410 LIN 02 Product or service ID qualifier. If billing for an NDC, enter N4.
2410 LIN 03 Product or service ID qualifier. If billing for drugs, include the 11-digit NDC.
2410 CTP 04 Quantity. If an NDC was submitted in LIN03, include the administered NDC quantity.
2410 CTP 05-1 Unit or bases for measurement code. If an NDC was submitted in LIN03, include the unit or basis for measurement code for the NDC billed. See Q6 for unit information.
2410 REF 01 VY: link sequence number.XZ: prescription number. The link sequence number is used to report components for compound drug.
2410 REF 02 Link sequence number or prescription number.  

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For DME rental charges incurred Jan. 1, 2018, and after, the provider is required to submit the purchase price when the HealthChoice allowed amount is $100 or more. HealthChoice will deny these claims when the purchase price is not included.

If you have questions, call the medical claims administrator at 800-323-4314.

4067

HealthChoice utilizes the 835 electronic remittance advice crosswalk table, which consists of claims adjustment reason codes (CARC), remittance advice remake codes (RARC) and explanation codes that are associated with claims processing.

4069

The EDI 835 transaction set, or electronic remittance advice (ERA), is part of the HIPAA standard transactions designed to improve claims revenue cycle management for providers. It is part of the ASC X12 835 health care claim payment/remittance advice.

Network providers should contact ECHO Health, a payment disbursement service, for changes to tax ID numbers, NPI numbers or other pertinent banking and clearinghouse information. All payment information, explanation of provider payment (EPP), and ERA will be available at ECHO Health’s multipayer portal, providerpayments.com.

Providers will receive the following ERA services that are currently available for HealthChoice at no cost:  

  • Download ERAs from providerpayments.com.
  • ERA routing to your designated clearinghouse.
    • To receive your ERA through your clearinghouse, please refer to information below.
  • Daily payment disbursement.
  • Payment issuance email notifications (set up through providerpayments.com).
  • Download ERAs from provider self-service at healthchoiceconnect.com.

For questions, call ECHO Health toll-free at 800-834-3511. 

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The HealthChoice Provider Network is comprised of over 26,000 medical and dental care practitioners and facilities. Most providers who are licensed and/or certified in their particular state are eligible to participate in the provider network. HealthChoice plan members have the ability to use health care providers from a wide range of specialties. The following specialties are eligible to participate in the HealthChoice Provider Network:

Ambulance Laboratory
Ambulatory Surgery Center Licensed Alcohol and Drug Counselor
Anesthesia Groups Licensed Behavioral Practitioner
Anesthesiology Assistant Licensed Clinical Social Worker
Audiologist Licensed Genetic Counselor
Birthing Center Licensed Marriage Family Therapist
Board Certified Assistant Behavioral Analyst Licensed Professional Counselor
Board Certified Behavioral Analyst Long-term Acute Care Facility
Cath Lab Medical Doctor
Certified Nurse Midwife Mental Health/Substance Abuse Facility
Certified Orthotist Ocularist
Certified Nurse Practitioner Occupational Therapist
Certified Prosthetist Ophthalmologist
Certified Registered Nurse Anesthetist Optometrist
Chiropractor Oral Surgeon
Christian Science Nurse Osteopathic Doctor
Christian Science Practitioner Pathologist (Individual)
Clinical Nurse Specialist Pathology Group
Dentist Perfusionist
Diabetes Prevention Program Organization Pharmacist
Dialysis Center Physical Therapist
Dietitian Physician
Durable Medical Equipment Vendor Physician Assistant
Emergency Physician Group Podiatrist
Hearing Aid Vendor Psychologist
Home Health Care Agency Radiologist (Individual)
Home Hospice Agency Radiology Group
Hospice Facilities Rehabilitation Facility
Hospital Skilled Nursing Facility
Hospitalist Group Sleep Study Provider
Independent Diagnostic Testing Facility Speech Language Pathologist
Infusion Therapy Center Urgent Care Clinic

HealthChoice also provides network reimbursement to rural health clinics, federally qualified health centers, Veterans Health Administration facilities, military facilities, city/county health departments, Indian Health Services facilities, radiation therapy centers and Metabolic Bariatric Surgery Accreditation and Quality Improvement Program Comprehensive Centers of Excellence. You can obtain contracts and applications through the HealthChoice Network Provider website or by contacting HealthChoice Network Management.

The contracts require network providers to make a reasonable effort to refer HealthChoice members and their dependents to other network providers when additional consults are necessary. EGID believes this referral process is in the best interest of the plan member and within the dictates of good medical practice. Plan members cannot realize the full benefit of their HealthChoice plan unless they utilize network providers. 

Refer to agency rules and HealthChoice contracts for specific requirements. 

4083

  1. This procedure describes the exclusive method of initiating any disputes related to HealthChoice Network Facility Contracts and Network Provider Acute Care Facility Contracts. The submission of a Request for Dispute Resolution Form to HealthChoice will signify good faith acceptance and agreement with all of the terms herein.
  2. The initiation of a dispute shall not require a party to delay or forego taking any action that is otherwise permitted by the network contract.
  3. HealthChoice has adopted this policy to provide a consistent method for the resolution of disputes with network facilities.
  4. Facilities who wish to dispute a decision by the HealthChoice Appeals Unit can submit a Request for Dispute Resolution within 45 days of the Appeals Unit’s final adverse determination. If not timely filed, the request will not be considered, and the matter will be deemed finally resolved. HealthChoice will have 45 days after submission to reach a determination.
  5. All Requests for Dispute Resolution must be submitted with a properly completed HealthChoice Request for Dispute Resolution Form. Forms must be mailed to HealthChoice at the address shown on the Form. Requests involving multiple similar claims must be accompanied by a spreadsheet including pertinent information on all claims. Requests submitted with insufficient supporting documentation will be returned.
  6. HealthChoice will not discriminate or retaliate against any facility due to participation in the Dispute Resolution process. All rights and conditions set out in the network facility contract will apply to the parties at all times, regardless of the existence of a Request for Dispute Resolution between the parties.
  7. Facilities are not permitted to pursue dispute resolution on behalf of a member or dependent. Facilities have agreed by contracting with HealthChoice that the permitted and non-permitted matters subject to this dispute resolution procedure are limited and listed in the network facility and Network Provider Acute Care Facility contracts at Section X. Dispute Resolution, paragraph 10.1. Facilities are not permitted to pursue, initiate or continue this dispute resolution process when the member or dependent timely exercises or has exercised their legal right to appeal the same claim or service that gives rise to the dispute specified by the facility.

3747

EGID recognizes your need for fee schedule information in order to conduct financial impact assessments. For your convenience, access to current HealthChoice fee schedule information is available to network providers through the HealthChoice Network Provider website at https://gateway.sib.ok.gov/feeschedule/Login.aspx.  

Disclaimer: This fee schedule is not 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.

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Future fee schedule updates for services provided by HealthChoice network providers are scheduled for: 

Date   ASC ADA ASA Bariatric  CPT HCPCS MS-DRG MS-DRG LTCH OP Select inpatient Select outpatient/
ASC
Jan. 1 A/C/D Comp Comp  A/C/D A/C/D A/C/D     Comp A/C/D Comp
April 1 Comp A/C/D   A/C/D Comp Comp     Comp A/C/D A/C/D
July 1 A/C/D A/C/D   A/C/D A/C/D A/C/D     Comp A/C/D A/C/D
Oct. 1 A/C/D A/C/D   Comp A/C/D A/C/D Comp Comp Comp Comp A/C/D

*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.

4170

Benefits are subject to the following guidelines: 

  • Limit of 20 visits allowed per calendar year without certification (refer to Speech Therapy for certification exception information). Maximum of 60 visits allowed per calendar year.
  • Treatments that exceed 20 visits per calendar year must be referred to HCMU for review. Manipulative therapy performed by an osteopath or medical doctor is also subject to these guidelines.

Referral forms for chiropractic, physical medicine, occupational therapy, physical therapy and speech therapy are completed and submitted to HCMU to initiate the certification process. The professional consultant can subsequently request additional documentation from the provider. The appropriate forms are available online

The following information is required on the referral form:

  • Diagnosis.
  • Summary of the case.
  • Approximate length of time treatments will be necessary.
  • Long- and short-term goals.

The following information may be requested by the professional consultant to support medical necessity:

  • Complete treatment plan.
  • History and physical.
  • Assessment of the patient’s response to treatment as determined during the initial examination and reevaluation.
  • Progress notes.

4076

Plan Administrator: Office of Management and Enterprise Services Employees Group Insurance Division

Network Management Unit

2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105

405-717-8790 
Toll-free 844-804-2642 
Fax 405-717-8977
EGID.NetworkManagement@omes.ok.gov
www.healthchoiceok.com

Medical and Dental Claims Administrator

Toll-free 800-323-4314
TTY 711

Hours 7:30 a.m. to 6 p.m., Monday through Friday, excluding state holidays

Payer ID:  71064

Providers are able to submit claims electronically through acceptable clearinghouses as identified by the medical and dental claims administrator using payer ID 71064.

New Claims, Correspondence and Medical Records

HealthChoice
P.O. Box 99011
Lubbock, TX 79490-9011

Appeals and Provider Inquiries

HealthChoice
P.O. Box 3897
Little Rock, AR 72203-3897

For medical records requests, please visit our webpage.

Health Care Management Unit 

2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105

405-717-8879 
Toll-free 800-543-6044, ext. 8879 
Fax 405-949-5459 and 405-949-5501

Certification Administrator

P.O. Box 99011
Lubbock, TX 79490-9011
Toll-free 800-323-4314
Fax 855-532-6780
TTY 711 Hours: 7:30 a.m. to 6 p.m., Monday through Friday, excluding state holidays

Pharmacy Benefit Administrator: CVS/caremark

P.O. Box 52136
Phoenix, AZ 85072-2136
Commercial (All non-Part D Plans)
Prior Authorization toll-free 800-294-5979 
Customer Care toll-free 877-720-9375
www.caremark.com

SilverScript (Medicare Part D)

Prior Authorization toll-free 855-344-0930 
Customer Care toll-free 866-275-5253 
www.healthchoice.silverscript.com

ECHO Health Services

Toll-free 888-834-3511
www.providerpayments.com

4077

The HealthChoice pharmacy network includes both independent and national chain pharmacies. There is also the option of mail service. Members can fill prescriptions for up to a 90-day supply at all HealthChoice network pharmacies at the same cost as using mail service.

For details regarding HealthChoice pharmacy benefits, including lists of commonly prescribed medications, excluded medications with preferred alternatives and specialty medications, visit the HealthChoice Pharmacy Benefits Information page at http://omes.ok.gov/services/healthchoice/member/pharmacy-benefits-information.

For information regarding network pharmacies and medication lists, call the pharmacy benefit manager toll-free at 877-720-9375. TTY users call 711.

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HealthChoice Select is a program designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed.

HealthChoice would like your facility to be part of the HealthChoice Select program. 

HealthChoice Select continues to increase the services covered under the program to include more of those with reasonably controllable cost variances, high consumer demand and market growth.

Advantages of participating in HealthChoice Select include: 

  • Procedures covered at 100% of allowable fees.*
  • No copays, coinsurance or deductibles to collect.*
  • Approximately 170,000 HealthChoice members in or near Oklahoma.
  • Potential to increase patient volume.
  • Dedicated provider directory on HealthChoice website.
  • Targeted marketing to HealthChoice members.

*Members of the High Deductible Health Plan must meet their deductible before any benefits, other than for preventive services, are paid by the plan.

Colonoscopies and sigmoidoscopies are covered under the program. To encourage members to participate in HealthChoice Select for these services, HealthChoice provides a $100 incentive payment to members.

For a list of services and procedures covered under HealthChoice Select, log in and access the Select fee schedule at https://gateway.sib.ok.gov/feeschedule/Login.aspx. You can also search for a list of services and procedures available through HealthChoice Select at https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx

Be aware that participating facilities are not required to provide all of the services covered under the program. Facilities can choose any combination of services and opt in or opt out at any time, according to existing contract notification provisions. 

To participate in HealthChoice Select, facilities must agree to and sign the contract amendment listed below for each location choosing to participate. Network management will provide the Attachment A with applicable services upon request.

For more information about participating in HealthChoice Select, please call network management at 405-717-8790 or toll-free 844-804-2642 or email EGID.NetworkManagement@omes.ok.gov.

Other Helpful Links:

HealthChoice Select FAQ
Select types of procedures and fee schedules
Select Mammography and Associated Services

Amendments:

HealthChoice Radiology and Sleep Study Facility Contract and First Amendment Select Amendment
HealthChoice Independent Diagnostic Testing Facility Amendment
HealthChoice Select Facility Amendment
HealthChoice Select Network Ambulatory Surgery Center Amendment

4117

Note: All CPT/HCPCS codes are subject to change.

Certification for all home health care services is required through the Health Care Management Unit. If you have questions or want to obtain certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. 8879.

Only one per diem per day for each authorized service can be certified.

For example, S9131 (PT, in home, per diem) and S9123 (nursing care, in home, by RN, per diem) can be certified at the same time for corresponding visits because they are different services. However, S9500 and S9501 cannot be certified at the same time because they are both for IV antibiotic therapy. If a patient is getting two antibiotic therapies at two different frequencies (e.g., every 24 hours and every 12 hours), it is up to the provider to determine which IV antibiotic per diem they will bill. IV medications are billed seperately.

As related to reimbursement, per diem represents each day that a patient is provided a prescribed visit. Refer to your current HCPCS codebook for more details regarding specific codes and per diems.

The following HCPCS procedure codes are not covered services:

HCPCS Code Description
G0151 Physical therapist in home health or hospice setting; each 15 minutes
G0152 Occupational therapist in home health or hospice setting; each 15 minutes
G0153 Speech/language pathologist in home health or hospice setting; each 15 minutes
G0155 Clinical social worker in home health or hospice setting; each 15 minutes
G0156 Home health or hospice aide in home health or hospice setting; each 15 minutes
S0274 Nurse practitioner visit at member's house, outside of a capitation arrangement

Refer to the CPT/HCPCS fee schedule for covered services.

4079

When filing claims, include accurate information pertaining to services rendered, including appropriate place of service and billing codes. HealthChoice cannot provide assistance with how to bill a claim; however, all claims are reviewed for billing accuracy, including, but not limited to, claims with billing codes S9490 through S9810. Home infusion therapy services are reimbursed at a per diem rate that is inclusive of equipment and supplies. Medication is reimbursed separately.

For all infusion therapy charges, certified home skilled nursing visits are not included in the HealthChoice allowed amount, but can be billed separately. Home health services should be billed by the provider rendering the services.

Home infusion therapy requires certification through the Health Care Management Unit. If you have questions regarding the certification process or to request certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. 8879.

4078

EGID has established a four tier system for short-term acute facilities:

  • Tier 1 – Network urban facilities with greater than 300 beds.
  • Tier 2 – All other urban and non-Network facilities.
  • Tier 3 – Critical access hospitals (CAH), sole community hospitals (SCH), Indian, military and VA facilities.
  • Tier 4 – All other Network rural facilities.

Annual updates to the base rate:

  • Tier 1 and Tier 2 – 100 percent of Medicare’s full market basket percentage.
  • Tier 3 – 50 percent of Medicare’s full market basket percentage.
  • Tier 4 – Remain frozen. For short-term acute facilities, Tier 4 remains frozen until Tier 2 base rate exceeds Tier 4.
  • Base rates will be reevaluated annually.

EGID has partnered with an outside vendor named VARIS, which will be conducting inpatient post-payment reviews. Medical records will be needed from your facility for this post-payment review if your claim is selected. For more information, refer to the Medical Record Request presentation.

HealthChoice utilizes the Centers for Medicare & Medicaid Services (CMS) local coverage determination guidelines for approval of intraoperative neurophysiologic monitoring claims.

View the most current version of LCD guidelines for IONM (L35003) by reviewing and accepting the CMS License Agreements.  

4144

Providers will receive one 1099 for each tax identification number. Even if you share a TIN with other providers, only one 1099 will be sent. This form will be addressed to the name registered with the Internal Revenue Service and mailed to the address indicated on your Form W-9.

4095

HealthChoice covers qualified laboratory urine drug screenings once per day per patient. As a reminder, HealthChoice covers only the following laboratory urine drug screens when medically necessary screening tests are required:

  • 80300 – Drug Screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures (e.g., immunoassay) capable of being read be direct optical observation, including instrument-assisted when performed (e.g., dipsticks, cups, cards, cartridges), per date of service.
  • G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter.

Clinical editing applies.

HealthChoice covers the following presumptive (qualitative) and definitive (quantitative) laboratory urine drug screenings when medically necessary. Laboratory screening and confirmation services are covered under the HealthChoice medical plan, subject to deductible, coinsurance, out-of-pocket maximums, clinical editing and all policy provisions.

  • Presumptive (qualitative) laboratory urine drug screenings are limited to 12 total per calendar year; certification is not required.
    • 80300 DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES.
    • G0477 DRUG TEST PRESUMP; CPBL BEING READ DC OPT OBV ONLY.
    • G0478 DRUG TEST PRESUMP; READ BY INSTRUM-AST DC OPT OBV.
    • G0479 DRUG TEST PRESUMP; INSTRUMENTED CHEMISTRY ANLYZER.
  • Definitive (quantitative) laboratory urine drug screenings are limited to four total per calendar year and certification is not required.
    • G0480 DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CL.
    • G0481 DRUG TEST DEFINITV DR ID METH P DAY 8-14 DRUG CL.
    • G0482 DRUG TEST DEFINITV DR ID METH P DAY 15-21 DR.
    • G0483 DRUG TEST DEFINITV DR ID METH P DAY 22/MORE DR CL.

If you have any questions regarding this change, please contact our medical claims administrator.

4084

A scan sheet is required to be attached to all medical or dental records to facilitate quickly matching the records with the correct claim. If records are submitted without the scan sheet, they will be returned to you.

Please do not submit records unless the claims administrator requests them. A separate scan sheet must be completed for each claim for which you are submitting records.

It is important that the claim number, found on your remittance advice, be included on the form.

The form is available for download at https://omes.ok.gov/services/healthchoice/providers/medical-records-requests.

For questions, call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.

4151

HealthChoice is contracted with SilverScript to provide Medicare Part D benefits. Providers should contact SilverScript when a member needs a medication not listed in the HealthChoice SilverScript Medicare Formulary.

This is an example of the Medicare Part D Identification Card:

4085

You can find a description of the plans offered by HealthChoice in the member handbooks at https://omes.ok.gov/services/employees-group-insurance-division/benefit-coordinator/handbooks.

4086

HealthChoice members are encouraged to utilize network providers for the delivery of medical and dental services and receive a financial benefit when using a network provider. When utilizing a HealthChoice Network Provider, the member is obligated to:

  • Provide evidence of coverage in the form of a HealthChoice ID card.
  • Assume the financial responsibility for deductibles, copays, coinsurance and non-covered services.
  • Cooperate with the provider in transactions involving any and all insurance carriers covering the member for services rendered.
  • Assist with and adhere to all aspects of the benefits offered through HealthChoice.

Below is sample identification card:

HealthChoice I.D. cards

V1.13749 

 

MS-DRG and MS-DRG LTCH Version 38 Fee Schedule Updates

The HealthChoice and Department of Corrections annual MS-DRG updates to acute inpatient reimbursement include updates to tier designations based on the number of beds and provider type designation as urban or rural as contained within the current year’s final IPPS file.

For charges incurred on and after Oct. 1, 2020, the following changes are effective for the HealthChoice and DOC MS-DRG fee schedules:

MS-DRG

Tier 1 2 3 4
Outlier Threshold $143,802.00 $110,452.00 $82,069.00 $77,479.00
Marginal Cost Factor 0.30 0.33 0.44 0.47
Base Rate $11,473.00 $10,659.00 $11,896.00 $10,824.00

The market basket update factor is 2.4%.

The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2021.

MS-DRG LTCH

For charges incurred on and after Oct. 1, 2020, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH fee schedules:

  • Version 38 of the MS-DRG LTCH fee schedule has a base rate of $55,965.00. The outlier threshold is $27,195.00 while the cost-to-charge ratio is 0.224 and market basket update factor is 2.3%.

The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2021.

If you have any questions regarding these adjustments, please call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.

4496

Effective April 1, 2020, there are CPT/HCPS codes identified with an NDC status indicator on the CPT, HCPCS and Outpatient fee schedules. Reference the NDC and procedure code combination on the NDC fee schedule for the allowable fee. Bill with the NDC code and the corresponding CPT/HCPCS code.

4437

HealthChoice Network Management is the primary source of information and assistance for providers participating in the HealthChoice Provider Network. 

Network management is responsible for: 

  • Performing the day-to-day duties necessary to manage the provider network, including the distribution of contracts, applications, and all other documentation utilized to obtain and store accurate provider information.
  • Maintaining the network provider database, which drives the HealthChoice Provider Search page, and the claims payment system.
  • Responding to provider inquiries regarding contract terms, reimbursement and basic claim issues, as well as member inquiries regarding issues that involve network providers.

Office hours are 8:00 a.m. to 4:30 p.m., Monday through Friday, excluding state holidays. 

HealthChoice Network Management 

2401 N. Lincoln Blvd., Ste. 300 
Oklahoma City, OK 73105  

405-717-8790 or toll-free 800-543-6044
Fax 405-717-8977

Email egid.networkmanagement@omes.ok.gov

Note: For a prompt reply, providers must send all written inquiries regarding contract information or any documentation intended for the network management staff directly to network management at the mailing address, email address or fax number referenced above. If correspondence is instead sent to the medical and dental claims administrator, there may be a significant delay in a response. 

4154

The Network News newsletter is the primary information source for HealthChoice Network Providers, delivering plan reminders and updates quarterly. Each issue meets notice requirements as set out in section XII of the Network Provider Contracts.

EGID distributes electronic versions of the newsletter and other communications to network providers from  healthchoice@service.govdelivery.com. To make sure you do not miss the newsletter or other communications, add this new email address to your safe senders list. 

4082

The network management unit is responsible for developing the content of the Network News newsletter. This newsletter is a quarterly publication specifically for network providers. The newsletter contains the latest information regarding plan benefits, contracts and fee schedules. The newsletter also serves as the primary method by which providers receive notifications mandated by the terms of the provider contracts.

To distribute the newsletter as efficiently as possible, it is distributed electronically to each network provider’s correspondence email address. Email addresses are obtained through information submitted on contract applications. Network management also updates email addresses on a regular basis as providers submit current information connected with their practice locations.

To update email information, network providers can use the appropriate change form located on the Provider Forms webpage. Completed forms can be submitted to network management by mail, fax or email.

It is imperative providers inform network management when contact information of any type is updated. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. The HealthChoice email address healthchoiceok@service.govdelivery.com should be added to the safe contact list so network management emails are not returned as undeliverable.

Printed newsletters are sent via the postal service to the mailing address on record for providers without internet access or those who have undeliverable email addresses.

V1.13750

The network provider contract gives EGID and the network provider the ability to terminate a contract with or without cause upon a 30-day written notice. Network providers must send letters of termination by certified mail per the terms of the contract. The return receipt serves as verification the information was received. The actual effective date of the termination is 30 days from the date EGID Network Management receives the termination letter. 

A provider is terminated immediately if their license is suspended or revoked or if their professional liability insurance is cancelled or not maintained in accordance with the network provider contract.

A network provider terminating with or without cause from the HealthChoice network is prevented from recontracting with HealthChoice for a period of 12 months following the effective date of termination, unless exceptional circumstances as determined by EGID Network Management require HealthChoice to execute a new contract. 

Please make a reasonable effort to inform all of your HealthChoice patients about your termination so they can make informed decisions about future provider utilization. 

4087

Members and providers have the option to nominate a medical or dental provider who is not a member of the HealthChoice Provider Network by submitting basic information on the provider search webpage.

Members and providers can also nominate facilities already participating in the HealthChoice Provider Network to be part of the HealthChoice Select program. The Select program is designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed. Only facilities can participate in HealthChoice Select, not individual practitioners.  

The contracting process may take at least several weeks. The provider or facility must satisfy our business requirements and meet our contracting standards. Nomination does not guarantee the provider or facility is eligible for participation in the network or will agree to contract with us. 

4088

HealthChoice covers orthodontic services for members under the age of 19; and for members ages 19 and older with temporomandibular joint dysfunction. Certification is required through the HealthChoice Health Care Management Unit for members aged 19 and older. For questions about certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. 8879. TTY users call 711. 

HealthChoice pays 50% of allowable fees, and there is no calendar year deductible or lifetime maximum benefit. A 12-month waiting period applies to all orthodontic benefits. The 12-month waiting period will be waived for services required for the treatment of TMD (regardless of age) but certification is required for treatment of TMD and the 12-month waiting period is waived as part of that process. 

Providers must submit one claim for the entire inclusive orthodontic course of treatment. The claim must include the banding date and the length of treatment in months. The payment for the first month of treatment is half the orthodontic benefit; the balance is payable in monthly installments over the remaining length of treatment so long as the patient remains eligible. 

This only applies to comprehensive orthodontic ADA codes. 

For questions about orthodontic benefits, call the claims administrator toll-free at 800-323-4314. TTY users call 711.  

Orthodontic benefits can be complicated, but to simplify the benefit for your ease of use, the chart below lists what is covered, not covered and what is all-inclusive.

  Description Benefit Clarification
D8010 Limited orthodontic treatment of the primary dentition. Covered and can bill separately.
D8020 Limited orthodontic treatment of the transitional dentition. Covered and can bill separately.
D8030 Limited orthodontic treatment of the adolescent dentition. Covered and can bill separately.
D8040 Limited orthodontic treatment of the adult dentition. Covered and can bill separately.
D8050 Interceptive orthodontic treatment of the primary dentition. Covered and can bill separately.
D8060 Interceptive orthodontic treatment of the transitional dentition. Covered and can bill separately.
D8070 Comprehensive orthodontic treatment of the transitional dentition. Covered and all-inclusive.
D8080 Comprehensive orthodontic treatment of the adolescent dentition. Covered and all-inclusive.
D8090 Comprehensive orthodontic treatment of the adult dentition. Covered and all-inclusive.
D8210 Removable appliance therapy. Covered and can bill separately.
D8220 Fixed appliance therapy. Covered and can bill separately.
D8660 Pre-orthodontic treatment visit. Covered and can bill separately.
D8670 Periodic orthodontic treatment visit. Not covered.
D8680 Orthodontic retention. Not covered.
D8690 Orthodontic treatment. Covered and can bill separately.
D8691 Repair of orthodontic appliance. Covered and can bill separately.
D8692 Replacement of lost or broken retainer. Covered and can bill separately.
D8693 Re-bonding or re-cementing; and/or repair, of fixed retainers. Covered and can bill separately.
D8999 Unspecified orthodontic procedure, by report. Each claim will be reviewed for coverage. Provide written description of dental necessity.

Note: All-inclusive includes retainer, appliances, etc. Not covered: This is the member’s responsibility.

4166

EGIDCY2018 Outpatient Hospital Reimbursement Fee Modeling for Cases with CMS J1 Status Indicators Using CMS J1 Methodology 

Introduction 

Under the CMS Hospital Outpatient Prospective Payment System OPPS, CPT codes assigned a J1 modifier in the CMS OPPS Addendum B are assigned to a comprehensive APC (C-APC). The single payment for the C-APC includes all services and items included on the outpatient claim. There are a few carve-out items that receive separate reimbursement. The C-APC is assigned based on the primary CPT code with a J1 modifier. A complexity adjustment is made for certain combinations of primary and secondary CPT codes.

EGID Application of CMS Policy

A) EGID will be applying similar bundling logic to its outpatient hospital claims beginning Jan. 1,2019. Claims with at least one CPT code that have a CMS J1 status indicator will be bundled intoa single unit reimbursement for the primary J1 CPT code. The following procedure/items will bebundled into the payment for the primary procedure:

  • Secondary procedures in the CPT range 10000-69999 or 92900-93999 (with or without aJ1 status indicator).
  • Units for the primary J1 procedure beyond 1.
  • Services that are typically bundled for hospital outpatient surgery claims under EGID’s April 2018 Outpatient Fee Schedule. Examples include: NC – non-covered services, UB-revenue code items without a vaild-CPT code, and CPT codes that are assigned a $0 fee.
  • Implants that are billed with just a UB-revenue code are not paid separately and arebundled into the J1 procedure fee.
  • All other items, procedures or services that CMS does not specifically carve-out as apass-through for J1 reimbursement (i.e., most lab, radiology, drugs and supplies will bebundled into the J1 procedure reimbursement).

B) The following items will be paid separately in accordance with the CMS methodology:

  • Diagnostic and screening mammograms.
  • Preventive services as defined in 42 CFR410.2.
  • Ambulance services.
  • Items, procedures or services that have a CMS OPPS Status Indicator of F, G, H, L or U.
    • F is for corneal tissue acquisition cost, certain CRNA services, and Hepatitis Bvaccines.
    • G is for pass-through drugs and biologicals.
    • H is for pass-through devices.
    • L is for influenza and pneumococcal pneumonia vaccines.
    • U is for brachytherapy sources.

Steps to Model J1 Reimbursement Using EGID Approach

  • Determine if the claim has a unit or units billed with a CPT code with CMS J1 status indicator. If it does go to the next step; otherwise, the claim will be reimbursed under the standard EGID hospital outpatient payment methodology.
  • Determine if the claim has multiple units of J1 procedure or procedures. If there is only one unit billed with one J1 CPT code, then the claim is a single procedure claim. The fee on the EGID hospital outpatient fee schedule will be the J1 reimbursement. All other services will be packaged and not paid separately unless the item is listed under B above. If the items are separately payable, then the EGID Hospital Outpatient Fee Schedule is referenced.
  • If the claim has multiple J1 units or J1 CPTs, then determine which CPT code has the highest CMS ranking. Use the CMS OPPS Addendum J schedule to determine the CPT ranking or the attachment. The lowest numerically ranked CPT code is defined as the primary CPT code for the claim. If there is not a complexity adjustment, the EGID Hospital Outpatient Fee Schedule will be the J1 reimbursement. All other services or procedures will be bundled and not reimbursed separately even if there is a separate fee assigned on the EGID Hospital Outpatient Fee Schedule unless it is a carve out item mentioned in B above.
  • Determine if the claim should have a complexity adjustment. Generally, CMS established the procedure oriented APCs with different levels of groups of surgeries. For example, APCs 5191-5194 are for endovascular procedures and there is an APC for each of the four levels of complexity. Certain combinations of procedures will receive a complexity adjustment to the next highest APC within the same family of procedures. The combinations of CPT codes and the next highest APC assigned are included in the CMS Addendum J or the attachment.
    • Use the table name CMS Complexity Adj APC Lookup to determine if the primary CPT with any of its secondary CPTs (or a second unit of the primary) are in the table and then therefore receive a complexity adjustment (i.e., the next highest level APC assignment).
    • If the CPT combination is included in the CMS Complexity Adj APC Lookup, then lookup the new APC Assignment (i.e., the Complexity Adjustment Assigned APC) in the next table – the excerpt from the CMS Addendum A with the EGID tier fees added to it. The higher payment is the new bundled fee for the multiple procedures on the claim. Note that many claims will not receive a complexity adjustment as it is only for a certain combination of CPT codes.
    • The bundling rules for other procedures and services will apply the same as described in above.

3839

The following are reimbursement changes that became effective April 1, 2016.

Utilize the same tier system previously established for short-term acute facilities:

  • Tier 1 – Network urban facilities with greater than 300 beds.
  • Tier 2 – All other urban and non-network facilities.
  • Tier 3 – Critical access hospitals (CAH), sole community hospitals (SCH), Indian, military and VA facilities.
  • Tier 4 – All other network rural facilities.
    • For short-term acute facilities, Tier 4 remains frozen until Tier 2 base rate exceeds Tier 4, which is estimated to occur in 2023. At that time, both short-term acute and outpatient Tier 4 facilities will move to Tier 2.

Changes will be phased in over three years:

  • April 1, 2016.
  • April 1, 2017.
  • April 1, 2018.

Code ranges that will be allowed as a tier-specific percentage of Medicare, with phase in as indicated in table below:

  • Surgery and other procedures within 10000-699999 that are not packaged by Medicare.
  • Cardiovascular and other procedures within 92900-93999 that are not packaged by Medicare.
  • HCPCS C codes that are not packaged by Medicare.
Tier April 1, 2016 April 1, 2017 April 1, 2018
1 220% 205% 180%
2 210% 195% 170%
3 230% 215% 200%
4 220% 205% 190%

Revenue codes

Covered revenue codes that are currently allowed at 60% or 70% of billed charges, generally packaged revenue codes, will initially be allowed at a reduced percentage of billed charges and then will be phased out.

Tier April 1, 2016 April 1, 2017 April 1, 2018
All 25% 10% No Payment

Covered implants will be allowed at the CPT/HCPCS allowable fee, or if no CPT/HCPCS code exists, then revenue codes 275, 276, 278 and 279 will be allowed at 30% or 35% of billed charges.

Tier April 1, 2016 April 1, 2017 April 1, 2018
1 30% 30% 30%
2 30% 30% 30%
3 35% 35% 35%
4 35% 35% 35%

Colonoscopy services

Allowable fees will begin at fully phased-in levels. 

Tier April 1, 2016 April 1, 2017 April 1, 2018
1 180% 180% 180%
2 170% 170% 170%
3 200% 200% 200%
4 190% 190% 190%

Revenue codes associated with colonoscopy procedures currently allowed at 60% or 70% will initially be allowed at reduced percentages of billed charges and then will be phased out.

Tier April 1, 2016 April 1, 2017 April 1, 2018
All 25% 10% No Payment

Allowable fees for procedures identified for the Select program will move to fully phased-in levels beginning with the first quarter following their inclusion in the program.

4121

If an overpayment occurs, the medical and dental claims administrator will notify providers in writing of the amount along with the related claim information. If the amount is in excess of $10,000, providers will be contacted by phone as well. If the overpayment is not satisfied within 150 days of the initial request, the medical and dental claims administrator will recover funds from another claim or claims from the same tax ID. If the overpayment cannot be satisfied within an additional 30 days, the medical and dental claims administrator can use its own resources or those of a third party to recover overpayments.

Providers can proactively refund overpayments, otherwise HealthChoice will begin recouping all overpayments at the tax ID level.

As an exception, EGID will immediately deduct overpayments due to resubmission of a corrected claim, or if information is received for a claim pending additional information that subsequently impacts a paid claim or a mutually agreed upon audit adjustment.

4145

If your patient requires a Step Therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department toll-free at 800-294-5979. TTY users call 711. 

The plan does not pay benefits for any of the following services, treatments, items or supplies, except as specifically provided for under Covered Services, Supplies and Equipment. Exclusions are not covered even if they are prescribed by a physician or if they are the only available treatment for the diagnosed condition. Some services may be medically necessary but not covered by the plan. 

A. Alternative treatments

  1. Acupressure.
  2. Biofeedback.
  3. Kinesiology (movement therapy).
  4. Rolf technique (Rolfing).
  5. Art therapy, music therapy, dance therapy, equine therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Integrative Health of the National Institutes of Health.

B. Dental

  1. Dental expenses that are covered under the dental plan.

C. Devices, appliances, prosthetics and supplies

  1. Devices that attach to a building (walls, ceilings, floors, etc.).
  2. Medical devices covered under pharmacy benefits are not covered, with the exception of diabetic testing supplies, ostomy supplies and products required by ACA.
  3. Over-the-counter disposable medical supplies such as bandages, tape, gauze pads, alcohol, iodine, peroxide, saline, etc.
  4. Devices, appliances, prosthetics and/or supplies, over-the-counter or otherwise, that are not primarily medical in nature and/or not considered medically necessary by the plan. Examples include, but are not limited to:  braces, compression garments, room humidifiers, air purifiers, pulse oximeters, blood pressure cuffs, exercise equipment, swimming pools, Jacuzzi pumps, saunas, hot tubs, automobiles or adaptive equipment for automobiles, sun lamps, augmentative communication devices, patient lifts, adaptive bathroom and self-care equipment, assistive devices, and cold/cryotherapy devices.
  5. Equipment that exceeds lifetime or maximum benefits (e.g., one walker per lifetime, one breast pump per pregnancy, one CPAP every five years).
  6. Mattresses not specifically designed for the prevention or treatment of skin breakdown or healing, or any other bedding purchased for any other reason.
  7. Lost, stolen or damaged (e.g., mold, insect, etc.) equipment or devices.
  8. Any device not FDA approved for general use or sale in the United States.
  9. Breast pumps provided by non-network suppliers/providers.
  10. Any covered items or services not used exclusively by the member or a covered dependent.

D. Drugs

  1. Products marketed with 510(k) clearance (FDA cleared).
  2. Prescription scar treatments.
  3. Off-label use of drugs (use of a drug for the treatment of conditions that are not indicated on the drug’s label).
  4. Over-the-counter drugs and vitamins (e.g., cough and cold drugs) except as required by ACA under pharmacy benefits.
  5. Drugs under investigation in approved clinical trials.
  6. Lost, stolen or damaged drugs.
  7. Any drug not FDA approved for general use or sale in the United States.
  8. Impotency drugs, unless following prostatectomy surgery.

E. Experimental/investigation services

  1. Any treatment, appliance/device, drug or procedure, including any particular aspect of a treatment, deemed or considered experimental or investigation by the plan.
  2. Items and services provided solely to satisfy data collection and analysis needs, including any service(s) not necessary for routine care such as specialized lab tests or drugs.

F. Personal care, comfort or convenience

  1. Items which are furnished primarily for personal comfort or convenience and/or are not primarily medical in nature.
    1. Includes but is not limited to exercise equipment, air purifiers, air conditioners, humidifiers, spas, elevators, telephones, tablets, computers, software applications, watches, televisions, cervical pillows, protective clothing or shoes, and supplies for hygiene or beautification.
  2. Exercise programs/fees/classes.
  3. Weight management/loss programs such as Weight Watchers, Jenny Craig, Diet Center, Zone diet or similar programs including any over-the-counter food or nutritional supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods or phytotherapy).
  4. Appetite suppressants.

G. Procedures and treatments

  1. Treatment of alopecia.
  2. Cosmetic or elective surgical procedures, treatments or drugs not necessary as the result of an accident with continuous coverage from the date of the accident to the date of corrective surgery.
    1. Complications from any such procedure not originally covered by HealthChoice.
  3. Breast reconstruction or implants not covered under the Women’s Health and Cancer Rights Act of 1998 and/or the Oklahoma Breast Cancer Patient Protection Act of 1998.
  4. Custodial care.
  5. Dyslexia testing.
  6. Electromyography without needle.
  7. Any routine hygienic foot/hand care, including trimming nails, and any other service rendered in the absence of localized illness, injury or symptoms involving the feet or hands.
  8. Home dialysis training.
  9. Home uterine monitoring.
  10. Marriage counseling.
  11. Medical services or treatments not generally accepted as the standard of care by the medical community.
  12. Weight-loss (bariatric) surgery that involves any of the following:
    1. Band and band revisions.
    2. Sleeve, bypass or duodenal switch performed outside of a network MSBSA-QIP certified comprehensive center for excellence.
    3. Revisions or complications to/from any procedure not originally covered by HealthChoice.
  13. Tobacco cessation counseling outside preventive service benefit coverage.
  14. Venipuncture by a physician when also billing for lab charges.
  15. Preoperative or postoperative care generally rendered by the operating surgeon, unless the surgeon itemizes his charges and the total amount charged is no more than the total allowable amounts for the surgery.
  16. Services provided in a school or daycare setting.
  17. Manipulative and physical therapy for palliative care (treatment for only the relief of pain), elective care (care designed to relieve recurring subjective symptoms), or prolonged care (treatment that does not move toward resolution as documented in the evaluation or re-evaluation goals).
  18. Any confinement, medical care or treatment not recommended by a duly qualified practitioner.
  19. Medical and/or mental health treatment of any kind, including hospital care, medications and medical care or medical equipment, which is excessive or where medical necessity has not been proven.
  20. Ultraviolet treatment – actinotherapy in the home (tanning beds).
  21. Cord blood banking, collection and storage.
  22. Speech therapy for learning disabilities or birth defects.

H. Providers

  1. Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient.

I. Reproduction/sexual health

  1. Infertility treatment, including artificial insemination, embryo transplant, in vitro fertilization, surrogate parenting, ovum transplant, donor semen, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and reversal voluntary sterilization.
  2. Sex transformation surgeries.
  3. Treatment for sexual dysfunction including implants of any nature except following a prostatectomy subject to state law.
  4. Surrogate mother expenses for non-covered participants.

J. Services provided under another plan or program

  1. Injury or sickness which is covered under an Extended Benefits provision of previous health coverage, until such time as such individual has exhausted all extended benefits available thereunder.
  2. Expenses to the extent the insured person is reimbursed or is entitled to reimbursement, or is in any way indemnified for such expenses by or through any public program, state or federal, or any such program of medical benefits sponsored and paid for by the federal government or any agency or subdivision thereof.
  3. Bodily injury or illness arising out of or in the course of any employment not specifically excluded by 85A O.S. 2013 § 2 of the Workers’ Compensation Code.
  4. Any services required by state or federal law to be supplied by a public school system or school district.

K. Vision and hearing

  1. Eye examinations for the fitting of corrective lenses or any charges related to such examinations, orthoptics, visual training for any diagnosis other than mild strabismus, eyeglasses, except for the first lens(es) used as a prosthetic replacement after the removal of the natural lens, other corrective lenses, or radial keratomy or LASIK (exceptions may apply to eye exams, refer to Preventive Services).
  2. Hearing aids and examinations for fitting or prescription.
  3. Batteries for hearing aids.

L. Other exclusions

  1. Charges for missed or cancelled appointments, mileage, penalties, finance charges, separate charges for maintenance, record keeping or case management services.
  2. Fees or retainers paid to concierge medicine providers.
  3. Claims submitted later than 365 days from the date of service.
  4. Medical care and supplies for which no charge is made or no payment would be requested if the insured individual did not have this coverage.
  5. Expenses incurred prior to the effective date of an individual’s coverage, or for expenses incurred during a period of confinement which had its inception prior to the effective date of an individual’s coverage.
  6. Hospitalization or other medical treatment furnished to the insured or dependent that begins after coverage has terminated.
  7. Complications from any non-covered or excluded treatments, items or procedures.
  8. Illness, injury or death as a result of committing or attempting to commit an assault or felony, including participation in a riot or insurrection as an aggressor.
  9. Intentionally self-inflicted injuries or illness, except when the injury (a) resulted from being the victim of an act of domestic violence or (b) resulted from a documented medical condition (including both physical and mental health conditions) that is covered under the health plan.
  10. Amounts billed for medical and surgical services and supplies in excess of the fee schedule for such services and supplies.
  11. Wrongful act or negligence of another when an employee or dependent has released the responsible party, unless subrogation has been waived or reduced in writing in an individual case, solely at EGID’s option, and only for good cause.
  12. Travel cost related to organ transplants.
  13. Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer.

4155

Network providers are reimbursed at 100% of the allowable fees for evaluation and management codes when billed using modifier 33 to identify them as preventive services. CPT code modifier 33 applies only to preventive services provided to pre-Medicare patients. Do not use modifier 33 for services already identified as preventive.

4122

Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice approves the medication for coverage at the appropriate tier.

Providers who request prior authorization must follow this process:

  1. The provider’s office must call the pharmacy benefit manager (PBM). Please have the member ID number, medication name and fax number ready.
  2. The PBM will do one of two things:
    1. Fax a prior authorization form to the provider’s office. The provider must complete this form.
    2. May be able to take the required information verbally over the phone. The representative will ask the necessary questions and record the answers given.
  3. Once their review is complete, the PBM sends notification of the review results to the member and the provider.
  4. If the medication is approved for coverage, the PBM loads the approval into their system within 24 to 48 hours. Written notification of the approval is faxed to the provider and sent to the member within 24 to 48 hours. If the prior authorization is not approved, written notification is faxed to the provider and sent to the member within 24 to 48 hours, along with information for appealing the denial.

For additional information about the HealthChoice pharmacy benefits, reference the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan Handbook at https://omes.ok.gov/services/employees-group-insurance-division/benefit-coordinator/handbooks or visit the pharmacy benefits information page at https://omes.ok.gov/services/healthchoice/member/pharmacy-benefits-information.

4089

Providers can appeal a claim payment or denial by submitting a letter to the medical and dental claims administrator at the designated address within one year of the date on the first notice of the adverse determination.

Network providers can request a second level appeal if the initial appeal is upheld and the network provider has additional information to submit for review. Second level appeals are only available to network providers.

Mail claim appeals and provider inquiries to:

HealthChoice
P.O. Box 3897
Little Rock, AR 72203-3897

For more information, call the claims administrator at toll-free 800-323-4314. TTY users call 711.

4139

The HealthChoice Provider Self-Service tool at https://gateway.sib.ok.gov/providerselfservice/Default.aspx is the primary search tool available for network providers to review pertinent information regarding contract demographic information, including physical and billing addresses, phone number, provider specialty, effective date and the last four digits of the providers TIN. The data is updated frequently to ensure network providers have access to the most accurate information available.

Should you find that any of the information listed is incorrect, please submit the appropriate change form along with an updated W9 to network management. Applicable change forms are available on the provider self-service site and on the HealthChoice provider site at https://oklahoma.gov/omes/services/healthchoice/providers/provider-forms0.html.

For questions, contact network management at EGID.NetworkManagement@omes.ok.gov or call 405-717-8970 or toll-free 844-804-2642. TTY users call 711.

4123

The terms of the HealthChoice contract require that network providers make reasonable efforts to refer their covered patients to other network providers for medically necessary services that they cannot provide or choose not to provide. This includes hospitals, medical supply companies, specialists, laboratories, etc.

Failure to refer to network providers will result in a review pursuant to the credentialing plan.

For additional information, please contact network management.

4090

Speech therapy is considered medically necessary for restoring existing speech lost due to disease or injury. Therapy must be expected to restore the level of speech the participant had before the disease or injury. It is not covered for treatment of learning disabilities or birth defects. The plan maximum is 60 speech language pathology visits each calendar year. Certification through HCMU is required for members ages 17 and younger.

Speech therapy services are also considered medically necessary for assessment and treatment of the diagnoses of pervasive developmental disorders (PDD) when the member meets any of the following criteria:

  1. Any loss of any language at any age.
  2. No two-word spontaneous (not just echolalia) phrases by 24 months.
  3. No babbling by 12 months.
  4. No gesturing (e.g., pointing, waving bye-bye) by 12 months.
  5. No single words by 16 months.

A request for a speech therapy evaluation for members 17 and younger must include a copy of the prescription or referral from a physician with documentation of the diagnosis. Requests for subsequent speech therapy visits must include a treatment plan from the speech pathologist with specific measurable goals and the expected amount, frequency and duration for therapy. There must be an expectation that the patient’s condition will improve significantly in a reasonable and predictable period. If at any point in the treatment it is determined that expectations will not be met, services will no longer constitute coverage for speech language pathology services. If the patient’s response to treatment is determined to be insignificant or at a plateau, continued coverage of speech services are excluded.

For additional information, please contact the Health Care Management Unit. Refer to Contact Information.

4092

The medical and dental claims administrator contracts with McAfee & Taft for subrogation recovery services. Subrogation is a plan’s right to seek reimbursement for an accident or injury caused by a third party such as a motor vehicle accident or a slip and fall.

When a claim denies for subrogation, the claims administrator sends the member a notification to contact McAfee & Taft, who then sends the member a letter and questionnaire requesting details about the medical services provided. The member may also complete the questionnaire online at www.mtsubrogation.com. Upon completion, the member is provided a confirmation number for their records. 

If the member does not provide the requested information to McAfee & Taft, the claim will be reprocessed accordingly as member responsibility.

4124

Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. 

The following is a comprehensive list of benefits for telehealth services available through network providers: 

  • HealthChoice covers telehealth services that may or may not be clinical in nature, including interactive audio and video services at an originating provider site between a member and distant site provider.
  • Institutional claims must include place of service (POS) 02 and indicate the GT or GQ modifiers to qualify for reimbursement.
  • Professional services only require the use of POS 02. Modifiers are not required. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance.
  • HealthChoice will acknowledge and pay telehealth claims according to the CPT, HCPCS and outpatient fee schedules.
  • HealthChoice excludes telepharmacy networks that use pharmacists to provide services.

All plan policies and provisions apply including HealthChoice claim editing guidelines. 

4140

All HealthChoice and the Department of Corrections (DOC) contracts contain timely filing provisions.

In order to move to a more industry standard time period for claims processing, HealthChoice and DOC accept new, clean claims or corrected claims received no later than 365 days following the date the service or supply was rendered. 

Providers are strongly encouraged to file claims according to the timely filing limits contained within their existing HealthChoice and DOC provider contracts. 

For additional information, call network management at 405-717-8790 or toll-free 866-573-8642. TTY users call 711. 

4147

In the case of a transfer, the transfer allowable fee for the transferring facility is calculated as follows:

Transfer allowable fee = (MS-DRG allowable fee/geometric mean length of stay) x (length of stay + 1 day).

The total transfer allowable fee paid to the transferring facility will be capped at the amount of the MS-DRG allowable fee for a non-transfer case. EGID will allow payment to the receiving facility if it is also the final discharging facility, at the MS-DRG allowable fee as if it were an original admission.

Discharge code Description Discharge procedure
01 Discharged to home or self-care (routine discharged) when beneficiary receives clinically related care that begins within three days after the hospital stay. The discharging hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
02 Discharged/transferred to a short-term general hospital for inpatient care. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
03 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care. The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
05 Discharged/transferred to a designated cancer center or children’s hospital. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
43 Discharged/transferred to a federal care facility. Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.
62 Discharged/transferred to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part until of a hospital rehabilitation distinct part (DP) units located in an acute care hospital or a CAH.  The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
63 Discharged/transferred to a Medicare certified long-term care hospital (LTCH). The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital. The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The payment to the receiving facility or unit is made at the rate of its respective payment system.
66 Discharged/transferred to a critical access hospital (CAH). Transfer policy will be applied to transfers from a short-term acute care hospital to short-term acute hospital.

 4091 

When services are rendered in place of service 20 Urgent Care Facility: location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention, the copay is $30 whether the patient is being seen by a primary care physician or specialist. This applies to the HealthChoice High and High Alternative Plans. High Deductible Health Plan members must first meet their deductible before the copay applies.  

4093

Each HealthChoice Network Provider is required to adhere to and cooperate with EGID’s certification and concurrent review procedures. These procedures do not guarantee a member’s eligibility or payable benefits, but assure the provider the medical necessity provisions have been met. The first step in the utilization review process is to verify benefits and eligibility. To obtain this information, network providers must contact the medical and dental claims administrator. The provider can also utilize the provider portal at www.healthchoiceconnect.com to obtain the information.

V1.13763

Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits.

CDC-recommended vaccinations, such as for shingles, are covered at 100% when using a network pharmacy. These can also be covered under the health benefit if provided by a recognized network health provider, such as a physician or health department.

Vaccine administration fees are also covered at 100% if the services are provided by a network provider. 

When using a non-network provider, members and dependents are subject to non-network benefits and can be balance billed for amounts above the allowable fees

  • Only network physicians or network providers can provide these services under the medical benefit.
  • Mid-level practitioners such as physician assistants and nurse practitioners practicing at a freestanding ambulatory care clinic located at a pharmacy may not be network.
  • Non-network pharmacists are not recognized and are not covered under the medical benefit.

Covered vaccinations include: 

  • Anthrax.
  • Flu.
  • Haemophilus Influenzae.
  • Hepatitis A.
  • Hepatitis B.
  • Human Papillomavirus.
  • Influenza A.
  • Influenza HD.
  • Japanese Encephalitis.
  • Measles.
  • Meningococcal.
  • Mumps.
  • Pneumococcal.
  • Poliomyelitis.
  • Rabies, Human Diploid.
  • Rabies, PF Chick-EMB Cell.
  • Rotavirus.
  • Rubella.
  • Shingrix (Shingles).
  • Smallpox (Vaccinia) Vaccine.
  • Tetanus Booster.
  • Tetanus, Diphtheria, Pertussis.
  • Typhoid.
  • Varicella.
  • Yellow Fever.
  • Zoster (Shingles).

This list is not all-inclusive. 

4125

While a procedure code may be listed on the fee schedule, all codes are subject to plan policies and provisions, including clinical editing and medical necessity guidelines. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

Venipuncture (36415) is not covered separately when lab work has also been performed and billed by the provider. For lab tests requiring routine venipuncture and subsequently sent to an outside lab, the physician office can bill either the venipuncture service or the handling charge, but not both. These services may be denied as incidental, or included in a primary service when billed in conjunction with another service. 

If further clarification is needed, please contact the claims administrator toll-free 800-323-4314.

A corrective lens can be covered only one time following cataract surgery. This lens should relate to the eye on which the surgery was performed. Frames are not a covered medical benefit.  

Contact lenses are covered only for the diagnosis of keratoconus, an uncommon condition of the eye surface. 

If you have questions, please contact the medical claims administrator. Refer to Contact Information

4094

The wig/scalp prostheses benefit is as follows: 

  • One wig or scalp prostheses per calendar year is covered for members who experience hair loss due to radiation or chemotherapy treatment resulting from a covered medical condition.
  • These must be obtained from a licensed cosmetologist or durable medical equipment provider.
  • For pre-Medicare plans, coverage is subject to calendar year deductible and coinsurance.
  • For Medicare supplement plans, coverage is not subject to calendar year deductible or coinsurance.
  • The wigs and scalp prostheses benefit will be paid per the HealthChoice fee schedule.

For questions about this benefit, call the medical claims administrator toll-free at 800-323-4314. TTY users call 711. 

4146

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