HealthChoice Provider Network News - Winter 2016

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Winter 2016


 

    IN THIS ISSUE

 

 

 

    NEWS

CVS/caremark Transition

Effective Jan. 1, 2016, CVS/caremark is the pharmacy benefit manager for HealthChoice. This transition from Express Scripts (ESI) to CVS/caremark includes formulary changes for both pre-Medicare health plan members and Medicare supplement plan members.

Pre-Medicare Health Plan Members

In November 2015, pre-Medicare members were notified by mail if one or more of their medications are excluded from the new formulary or if they are negatively impacted by formulary changes. The letter included a list of available Preferred alternative medications from the new formulary. Pharmacy prior authorizations in effect on Dec. 31, 2015, for pre-Medicare members were transferred from ESI to CVS/caremark. To request prior authorizations after Jan. 1, contact CVS/caremark toll-free at 1-800-294-
5979.

Medicare Supplement Plan Members

While HealthChoice has terminated its Part D contract with the Centers for Medicare & Medicaid Services
(CMS) effective Jan. 1, 2016, Part D benefits continue to be provided to our members through the contract with CVS/caremark and its SilverScript Employer Prescription Drug Plan.

CMS does not allow prior authorizations to transfer between Part D contracts. As a result, HealthChoice Medicare supplement plan members who had a prior authorization through ESI are required to obtain a new one through CVS/caremark. Members are able to get a transition fill for the first 90 days of the new plan year. After the member receives the transition fill, members and providers will be notified by mail that a new prior authorization is required to fill the prescription in the future. To request Part D prior authorizations after Jan. 1, contact CVS/caremark toll-free at 1-855-344-0930.

CVScaremark

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New Reimbursement Methodology for Outpatient Facility Claims

For charges incurred on or after April 1, 2016, HealthChoice and DOC have adopted a new reimbursement methodology for outpatient facility claims. Please visit our website at https://www.ok.gov/sib/Providers/Public_Hearing_-_Outpatient_Hospital_Facility_Notice.html for more information.

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Changes to Coverage Criteria for Mastectomies

Effective for charges incurred on or after April 1, 2016, HealthChoice is updating the criteria for coverage of a risk-reduction mastectomy (RRM). An RRM will be covered if there is a significantly elevated risk of breast cancer as indicated by one or more of the following:

  • Genetic mutation conferring a high-risk for breast cancer (e.g., BRCA1/2, PTEN, TP53, CDH1, STK11)
  • Other hereditary breast cancer syndrome or mutation (e.g., Cowden syndrome, Li-Fraumeni syndrome)
  • Lifetime risk of breast cancer estimated to be greater than 20 percent (e.g., based upon models that take into account family history such as the Claus or Tyrer-Cuzick prediction tools)
  • Noninvasive histology indicating risk (e.g., lobular carcinoma in situ)
  • Patient received therapeutic thoracic irradiation before age 30

If you have questions, please contact the medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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HealthChoice Select

On Jan. 1, 2016, HealthChoice introduced a new optional program called HealthChoice Select. This 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 costs associated with the service. The services covered under HealthChoice Select will be covered at 100 percent of Allowable Fees with no out-of-pocket costs to members.

HealthChoice Select is available to members of the HealthChoice High, High Alternative, Basic, Basic Alternative, and FOCUS Plans and the High Deductible Health Plan.

Facilities that elect to participate in HealthChoice Select must agree to bundle all costs associated with a service and bill HealthChoice one single amount. HealthChoice will make one payment to the facility that will incorporate facility fees and professional fees, including anesthesiology. The facility will be responsible for paying the physicians and other practitioners for the services they provide.

To participate in HealthChoice Select, facilities must sign a HealthChoice Select amendment and a related Attachment A for each type of service they choose to provide under the program. Initially, only colonoscopies and sigmoidoscopies will be covered under HealthChoice Select; however, HealthChoice will be working to increase the types of services covered under the program. Facilities will be provided the opportunity to sign a specific attachment for each type of service added to the program.

A separate fee schedule, which can be found in the secure fee schedule search area on the HealthChoice website, will apply to the services covered under HealthChoice Select. The Allowable Fee for each service will apply only to those facilities that have signed an Attachment A to provide that service under the program. Currently, only the Allowable Fees for charges incurred on or after Jan. 1, 2016, for colonoscopies and sigmoidoscopies are included in the fee schedule.

HealthChoice will increase the number of facilities participating in the new program and the types of procedures covered under bundled pricing in April 2016.

Facilities interested in obtaining more information about the program should contact Teresa South, EGID Director Network Management at 1-405-717-8627 or toll-free 1-844-804-2642. Email inquiries can be sent to Teresa.South@omes.ok.gov.

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Attention All Providers

Providers will receive one 1099 for each tax identification number (TIN). If you share a TIN with other providers, there will still be only one 1099 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.

If you have questions regarding your 1099, please contact our medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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Eligible Transplants

For charges incurred on or after April 1, 2016, the transplants covered by HealthChoice are as follows:

  • Bone Marrow
  • Corneal
  • Heart
  • Intestinal
  • Kidney
  • Liver
  • Lung
  • Pancreas
  • Peripheral Stem Cell

Certification is required for all transplants. If you have questions about certification for a HealthChoice member, please contact our certification manager. If you have other questions, please contact our medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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HealthChoice FOCUS Plan

HealthChoice FOCUS is a new plan effective Jan. 1, 2016, available to pre-Medicare former employees and surviving dependents in the designated ZIP code service areas of Canadian, Cleveland, Comanche, Garfield, Grant, Logan, McClain, Oklahoma, Payne and Stephens counties.

The HealthChoice FOCUS Provider Network is comprised of clinically-integrated providers who are committed to a collaborative approach to care and are affiliated with Oklahoma Health Network (OHN), which includes the following groups:

  • Comanche County Health Partners (Lawton)
  • INTEGRIS Health Partners (Oklahoma City Metro and Enid)
  • Duncan Health Partners (Duncan)
  • Norman Physician Hospital Association (Norman and Moore)
  • Stillwater Medical Center (Stillwater)

Please note that not all providers contracted with the HealthChoice Provider Network participate in the FOCUS Provider Network. The HealthChoice website and the OHN website have links to the list of providers participating in the new network. HealthChoice FOCUS members receive Network benefits only when they use a HealthChoice FOCUS Network Provider. If you have not contracted with OHN for the HealthChoice FOCUS Plan, any claims for HealthChoice FOCUS members will process at the non-Network benefit level.

Please share this information with your scheduling staff so they do not inadvertently schedule appointments for FOCUS plan members if you are not a member of the FOCUS Provider Network.

For more information, visit the HealthChoice website at www.healthchoiceok.com. Under the “Current News” heading on the main page, there is an article that further explains the benefits of the HealthChoice FOCUS Plan. You can also search the “FAQ” section for more information. Under the “Find a Provider” tab, you can search for HealthChoice FOCUS Network Providers.

Questions regarding claims, eligibility or benefits should be directed to our medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter. Questions regarding HealthChoice FOCUS Network Providers should be directed to OHN Customer Service at 1-405-652-1041 or toll-free at 1-855-445-1471. You can also visit their website at www.ohnonline.com/focus.

HealthChoice FOCUS

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Certification Requests Via ClaimLink Coming Soon

The Office of Management and Enterprise Services Employees Group Insurance Department (EGID) will
be accepting certification requests via ClaimLink in 2016. ClaimLink is an online service that currently allows providers to inquire about a patient’s eligibility, submit dental and professional claims, check the status of claims, and view remittance advices.

You can access ClaimLink via the EGID website at www.sib.ok.gov or directly at https://www.okhcp-eds.com/HCP/.

After logging in to ClaimLink, you, or your delegate, will be able to submit an inquiry regarding a certification. Instructions will be available on ClaimLink to assist you with the new functionality.

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Dental X-rays Update

Dental X-rays are often included unnecessarily when dental claims are submitted. If X-rays are needed to process a claim, the dental claims administrator will request them.

Effective April 1, 2016, HealthChoice will return dental X-rays to the member or provider only upon request. Please submit dental X-rays only when requested by the dental claims administrator.

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Update to Contraceptive Coverage

For charges incurred on or after Jan. 1, 2016, the HealthChoice preventive services benefit for implantable rods or IUD insertions and removals has been updated to cover one procedure every three calendar years. This benefit applies to all female HealthChoice health plan members and dependents ages 18 and older. When all Plan provisions are met, these preventive services are covered at 100 percent of the Allowable Fee when using Network Providers.

If you have questions regarding this change, contact our medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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Fee Schedule Updates

On Jan. 1, 2016, HealthChoice and the Department of Corrections (DOC) updated the CPT/HCPCS, Outpatient Facility (OP), Ambulatory Surgery Center (ASC), American Society of Anesthesiologists (ASA), and American Dental Association (ADA) fee schedules. Additionally, significant fee schedule updates will be effective April 1, 2016.

HealthChoice and DOC provide fee schedule updates on Jan. 1 of each year that reflect added, changed and deleted codes; however, the comprehensive annual fee schedule update occurs on April 1 of each year. This allows time for the Centers for Medicare & Medicaid Services (CMS) to finalize and post its fee schedules. The next scheduled updates are:

  • Feb. 1: Add, change and delete codes for ASA
  • April 1: Comprehensive fee schedule update for CPT/HCPCS, OP, ASC, and ADA

As a reminder, the American Medical Association periodically changes, adds, corrects or deletes procedure codes throughout the year. When these modifications occur, HealthChoice and DOC review them as soon as possible and make any necessary changes. Additionally, the Office of Management and Enterprise Services Employees Group Insurance Department makes fee schedule updates on an ad hoc basis when necessary.

Inpatient and outpatient tier designations are updated on Oct. 1 each year, based on the most current CMS fiscal year inpatient prospective payment system (IPPS) impact file for Network Providers.

For charges incurred on or after April 1, 2016, HealthChoice and DOC have adopted a new reimbursement methodology for outpatient facility claims. Please visit our website at https://www.ok.gov/sib/Providers/Public_Hearing_-_Outpatient_Hospital_Facility_Notice.html for more information.

Fee schedule updates are reported in each issue of the Network News which is distributed quarterly to all Network Providers. Updates are also posted to the provider websites. We encourage you and your staff to reference the website of your provider network for the most recent fee schedule updates and other important information.

If you have questions, please contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter. Email inquiries can be sent to EGID.NetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov.

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Claims that Contain Both ICD-9 and ICD-10 Diagnosis Codes

HealthChoice, the Department of Rehabilitation Services and the Department of Corrections have adopted the Centers for Medicare & Medicaid Services (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.  Failure to follow CMS guidelines will result in either your clearinghouse rejecting your claim or our 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 claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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HIPAA 278 Transactions Available in 2016

The Office of Management and Enterprise Services Employees Group Insurance Department is accepting HIPAA X12N version 5010 278 – Health Care Services Review – Request for Review and Response Transactions in 2016.

The 278 facilitates the exchange of information between providers and review entities for:

  • Admission certification reviews;
  • Referral reviews;
  • Health care services certification reviews;
  • Extend certification reviews;
  • Certification appeal reviews;
  • Reservations of medical services; and
  • Cancellations of medical services reservations.

The 278 transaction is one of the standard transactions covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for the health care industry to achieve administrative cost savings with electronic data interchange (EDI). It is also one of the transactions covered under section 1104 of the Patient Protection and Affordable Care Act for the use of operating rules to support implementation of HIPAA standards.

Health care service providers are not required to utilize the standard transactions; however, if you choose to submit EDI transactions, the standards and operating rules must be followed.

These transactions will be accepted in batch mode from Emdeon, and Emdeon will return responses to providers.

For more information regarding the format of the 278 transaction and for implementation assistance, refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12N/005010X217, Health Care Services Review – Request for Review and Response (278) Implementation Guide. The guide is available through Washington Publishing Company, www.wpc-edi.com.

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Modifier 59 Clinical Editing Changes Will Effect Reimbursement

For charges incurred on or after Jan. 1, 2016, clinical editing for Modifier 59 will be applied with the appropriate modifiers. These modifiers are used only for tracking and reporting purposes.

a. 59 – Distinct Procedural Service
b. PO – Surgeries, procedures and/or surgeries provided at off-campus provider-based outpatient departments
c. XE – Separate encounter, a service that is distinct because it occurred during a separate encounter
d. XP – Separate practitioner, a service that is distinct because it was performed by a different practitioner
e. XS – Separate structure, a service that is distinct because it was performed on a separate organ/structure
f. XU – Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

Network Providers can model clinical editing through “ClaimLink.” Go to www.healthchoiceok.com/providers and select “ClaimLink” in the top menu bar.

For more information or if you have questions regarding this change, please contact the medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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MS-DRG and MS-DRG LTCH Version 33 Fee Schedule Updates

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

For charges incurred on and after Oct. 1, 2015, the following changes are effective for HealthChoice and DOC MS-DRG fee schedules:

MS-DRG

MS DRG

The market basket update factor is 2.4 percent.

The next comprehensive MS-DRG fee schedule update will be effective for charges incurred on or after Oct. 1, 2016.

MS-DRG LTCH

For charges incurred on and after Oct. 1, 2015, the following changes are effective for HealthChoice and DOC MS-DRG LTCH fee schedules:

  • Version 33 of the MS-DRG LTCH fee schedule has a base rate of $51,423. The outlier threshold is $16,423 and the cost-to-charge ratio is 0.246.

The next comprehensive MS-DRG LTCH fee schedule update will be effective for charges incurred on or after Oct. 1, 2016.

If you have any questions regarding these adjustments, please contact the medical and dental claims administrator. Refer to "Network Provider Contact Information" at the end of this newsletter.

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Dental and Endodontic Fee Schedule Update for 2016

For charges incurred on or after Jan. 1, 2016, HealthChoice and the Department of Corrections (DOC) have updated the dental and the endodontic fee schedules with code changes implemented by the American Dental Association. The Allowable Fees have also been updated.

For the most current fee schedule, please visit our website at www.healthchoiceok.com/providers or contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter.  Email inquiries can be sent to EGID.NetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov.

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Clarification of Dental Code D9910

HealthChoice is clarifying the criteria for use of the American Dental Association (ADA) code D9910 – Application of Desensitizing Medicament for charges incurred on or after April 1, 2016. Code D9910 is a covered benefit under the HealthChoice Dental Plan and does not require certification.

Code D9910 is typically reported on a per visit basis for application of topical fluoride. It is not to be used for bases, liners or adhesives used under restorations, as such use is considered part of the restorative procedure. This clarification will be reflected in the online dental fee schedule and the HealthChoice Provider Manual.

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Online Access to Claims and Eligibility

Network Providers have access to “ClaimLink,” our powerful, secure website designed to quickly enter claims, request dental predeterminations, check eligibility and claims status, and obtain electronic remittance advices. Visit our website at www.healthchoiceok.com and select “ClaimLink” in the top menu bar then select “here” at the end of “Providers and facilities can access ClaimLink for Providers here.”  Registration is quick, easy and secure.

Network Providers who use “ClaimLink” to enter claims for services or dental predeterminations generally receive a response the next business day. Online claims submission is a much more efficient method of submitting claims. It significantly reduces processing errors and improves the turnaround times for claims payments. A presentation that outlines the online claims submission process is available once you log into the application.

If you have questions regarding “ClaimLink” or need assistance registering, please contact our medical and dental claims administrator. Refer to “Provider Network Contact Information” at the end of this newsletter.

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Changes to Remittance Advices and ClaimLink

Maintaining confidentiality is especially important to patients seeking treatment for sensitive issues, and improvements in our privacy processes are made on an ongoing basis.

In order to better maintain patient confidentiality, HealthChoice, the Department of Rehabilitation Services and the Department of Corrections have removed the “Code” header and the “Code Description” from “Remittance Advices” and “ClaimLink” for all claims processed on or after Jan. 1, 2016. The certification administrator has also removed all references to coding/description from all communications.

For additional information, please contact the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.

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Help HealthChoice Members and Dependents be Tobacco-free

Quitting Is The Goal

HealthChoice is committed to better health, and a major part of that commitment is to continually focus on tobacco cessation. Please encourage HealthChoice members and dependents to quit for good by keeping them informed of the health risks and treatment options.

QUIT Program

Through a cost-sharing agreement with Oklahoma Tobacco Research Center, HealthChoice health plan members and dependents ages 13 and older can receive five phone coaching sessions and up to 12 weeks of over-the-counter tobacco cessation products, including gum, patches or lozenges, at no cost through the Oklahoma Tobacco Helpline (1-800-QUIT-NOW).

HealthChoice Preventive Services and Enhanced Tobacco Cessation Benefits

HealthChoice health plan members and dependents ages 18 and older can also receive one free annual tobacco cessation/tobacco-related disease counseling visit to a HealthChoice Network health provider (billing code: 99406); as well as two 90-day courses per plan year of prescription tobacco cessation products at no cost when they are received through a Network Pharmacy. Covered products include:

  • Buproban 150mg SA Tabs
  • Bupropion HCL SR 150mg Tabs
  • Chantix 0.5mg and 1mg Tabs
  • Nicotrol 10mg Cartridge
  • Nicotrol NS 20mg/m Nasal Spray

For more information, visit www.healthchoiceok.com.

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Network Provider Contact Information

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

CVS/caremark
Pharmacy Prior Authorization Request
Toll-free 1-800-294-5979
Pharmacy Prior Autorization Request – SilverScript (Part D)
Toll-free 1-855-344-0930

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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Please share the Network News with:

  • Office managers
  • Referral and certification staff
  • Business office staff
  • Front office staff
  • Medical records staff
  • Providers