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The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets for all charges incurred on or after Oct. 1, 2015. The structure of ICD-9 codes limits the number of new codes that can be created, and many ICD-9 categories are full.
ICD-10 codes will affect diagnosis and inpatient procedure codings for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just providers who submit only Medicare or Medicaid claims.
Claims that contain both ICD-9 and ICD-10 Diagnosis Codes
Please be aware that HealthChoice, the Department of Rehabilitation Services and the Department of Corrections have adopted CMS guidelines for handling claims for charges incurred prior to Oct. 1 and after Oct. 1, 2015. Providers and facilities cannot submit one claim with charges incurred prior to Oct. 1 and charges incurred on or after Oct. 1. ICD-9 and ICD-10 codes cannot be submitted on the same claim; they must be submitted on two separate claims. Failure to follow these CMS guidelines will result in either your clearinghouse rejecting your claim or our medical and dental claims administrator denying your claim. For specific claim filing guidelines, please visit the CMS website at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/SE1408.pdf.
If you have any questions, please contact our medical and dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
ICD-10 Testing Requested
Testing is crucial for the implementation of ICD-10 codes. The testing process will aid in the smooth transition to claims processing under the new coding guidelines. Do not wait to submit test claims as this may ultimately cause delays in the accurate and timely processing of your claims. Send your test claims now so any claim issues related to this change can be identified and resolved.
Contact your clearinghouse to begin the ICD-10 testing process. You can test directly with Emdeon Business Services LLC® Testing Exchange or Nuesoft Technologies, Inc. If you use a different clearinghouse, please contact them and ask them to work directly with Emdeon or Nuesoft.
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HealthChoice covers certain preventive services at 100% of Allowable Fees when Network Providers use specific diagnosis codes. For charges incurred on or after Oct. 1, 2015, ICD-10 codes must be used.
This change impacts the coding for the preventive services below. Claims for these services must include the correct ICD-10 codes. The codes that are changing are in bold.
- Colorectal Cancer, Screening – One colon/sigmoidoscopy every three years for members and dependents ages 50 through 75 with diagnosis codes V12.11 and V12.12. Billing codes include 45378, G0121, G0105 and any other CPT/HCPCPS codes for colon/sigmoidoscopies.
- Pediatric Preventive Health Care "Bright Futures" – Children up to age 20. Additional benefits include all services on the same day of the preventive visit that have ICD-10 preventive service diagnosis codes.
If you have questions regarding this change, contact our medical and dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
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Beginning in 2016, the HealthChoice pharmacy benefit manager will change from Express Scripts to CVS/caremark. CVS/caremark will begin processing claims for HealthChoice members on Jan. 1.
Look for more information on this upcoming change in the fall edition of the Network News.
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HealthChoice, the Department of Rehabilitation Services and the Department of Corrections are now working with DentalXChange, a clearinghouse for dental providers, for the submission of electronic claims and receipt of electronic remittance advices (ERAs).
For additional information or to sign up for electronic claims submission and ERAs, please visit our website at www.healthchoiceok.com or contact network management at 1-405-717-8790 or toll-free 1-844-804-2642. Email inquiries can be sent to EGID.NetworkManagement@omes.ok.gov.
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HealthChoice and the Department of Corrections (DOC) have reviewed their fee schedules for CPT/HCPCS, Outpatient Facility (OP), Ambulatory Surgery Center (ASC), American Society of Anesthesiologists (ASA), and American Dental Association (ADA) codes. As stated in earlier notifications, there may be changes effective for charges incurred on or after July 1, 2015.
The next quarterly fee schedule review for possible updates will affect charges incurred on or after Oct. 1, 2015, for CPT/HCPCS, OP, ASC, ASA, and ADA codes. A comprehensive fee schedule update for MS-DRG and MS-DRG LTCH codes will also be effective for charges incurred on or after Oct. 1, 2015.
As a reminder, the American Medical Association periodically changes, adds, corrects and/or deletes procedure codes. When these changes occur, HealthChoice and DOC review them as soon as possible and make necessary updates. Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis as needed.
Fee schedule updates are reported in each quarterly issue of the Network News. If you need specific codes and Allowable Fees affected by these updates, please visit our website at https://gateway.sib.ok.gov/feeschedule and view or download the latest fee schedule addendum.
If you have questions or need additional information, please contact network management at 1-405-717-8790 or toll-free 1-844-804-2642. Email inquiries can be sent to EGID.NetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov.
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Did you know that the Employees Group Insurance Department also maintains the Department of Rehabilitation Services (DRS) Provider Network? DRS expands opportunities for employment, independent life and economic self-sufficiency by helping Oklahomans with disabilities bridge barriers to success in the workplace, school and home. DRS operates dozens of programs that help Oklahomans lead more independent and productive lives by aiding with:
- Assistive technology
- Education
- Employment services
- Health and mental health services
- Housing assistance
- Personal assistance and in-home services
- Transportation
The goal of DRS is to provide rehabilitation and the opportunity for independent living for disabled Oklahomans. Your help as a health professional is needed to achieve this goal. We encourage you to reach out and become a DRS Network Provider today!
For more information, please visit our network provider home page at gateway.sib.ok.gov/DRS, email network management at EGID.DRSNetworkManagement@omes.ok.gov or call network management at 1-405-717-8921 or toll-free 1-888-835-6919.
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For the fastest claims processing, submit claims electronically or through "ClaimLink."
If you consistently have issues with 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 because it takes much longer to process paper claims.
Use the current claim form to expedite claims processing. Accepted claim forms include the ADA 2012*, CMS 1500 (02-12) and UB-04.
If we request additional documentation to process a claim or if you need to file a corrected claim, please submit the information or corrected claim to:
HP Administrative Services, LLC
P.O. Box 24110
Oklahoma City, OK 73124-0110
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 health and dental claims administrator or log in to "ClaimLink" to check the claim 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.
If you have questions, please do not hesitate to contact our medical and dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
*Dental providers: For faster service and to save time and expense, please do not send dental X-rays or molds with your claims or dental predeterminations unless they are requested by HealthChoice.
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An electronic remittance advice (ERA) is an electronic version of your explanation of payment. It contains the same details as the paper version you normally receive. Receiving ERAs can provide numerous benefits to any medical practice, such as:
- Quick, easy receivables reconciliation;
- Less time spent opening mail, filing, and making phone calls to health insurers;
- Elimination of paper remittances;
- Fast turnaround for claims to secondary payers; and
- More time to focus on revenue-enhancing functions.
If you would like more information about ERAs, please contact network management at 1-405-717-8790 or toll-free 1-844-804-2642, or send email inquiries to EGID.NetworkManagement@omes.ok.gov.
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For charges incurred on or after April 1, 2015, HealthChoice and the Department of Corrections began covering 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 by 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.
Note: No other Definitive Drug Testing and Presumptive Drug Class Screening CPT codes are covered.
If you have any questions regarding this change, please contact our medical and dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
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HealthChoice Providers
www.healthchoiceok.com
Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
Customer Service and Claims
OKC Area 1-405-416-1800
Toll-free 1-800-782-5218
FAX 1-405-416-1790
TDD 1-405-416-1525
Toll-free TDD 1-800-941-2160
Pharmacy
Express Scripts
Pharmacy Prior Authorization for Preferred/Non-Preferred or Brand/Generic
Toll-free 1-800-841-5409
Other Pharmacy Prior Authorization
Toll-free 1-800-753-2851
Certification
APS Healthcare
P.O. Box 700005
Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121
Toll-free TDD 1-877-267-6367
FAX 1-405-416-1755
HealthChoice Health Care Management Unit
OKC Area 1-405-717-8879
Toll-free 1-800-543-6044, ext. 8879
HealthChoice Network Management
OKC Area 1-405-717-8790
Toll-free 1-844-804-2642
DOC Network Management
https://gateway.sib.ok.gov/DOC
OKC Area 1-405-717-8750
Toll-free 1-866-573-8462
DOC Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 268928
Oklahoma City, OK 73126-8928
Toll-free 1-800-262-7683
DRS Network Management
https://gateway.sib.ok.gov/DRS
OKC Area 1-405-717-8921
Toll-free 1-888-835-6919
DRS Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 25069
Oklahoma City, OK 73125-0069
Toll-free 1-800-944-7938
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