Network News Spring 2016

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Spring 2016

 


 

    IN THIS ISSUE

 

 

 

    NEWS

Be a Part of the HealthChoice Select Program

HealthChoice would like your facility to be part of the HealthChoice Select Program. 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 costs associated with the service on the date the surgery or procedure is performed.

Effective April 1, 2016, HealthChoice increased the services covered under the Select program to include more of those with reasonably controllable cost variances, high consumer demand, and market growth.

Advantages of participating in the HealthChoice Select Program include:

  • Procedures covered at 100 percent of Allowable Fees;
  • No copays, coinsurance and/or deductibles to collect;
  • Approximately 170,000 HealthChoice members in or near Oklahoma;
  • Potential to increase patient volume;
  • Dedicated provider directory on HealthChoice website; and
  • Targeted marketing to HealthChoice members.

Visit the Web page at https://www.ok.gov/sib/Providers/HealthChoice_Select/index.html for a full list of the services available under HealthChoice Select. 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.

For more information about participating in HealthChoice Select, 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.

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Benefit Change for CPAP and BiPAP Supplies

HealthChoice currently covers one set of supplies for continuous positive airway pressure (CPAP) machines and bi-level positive airway pressure (BiPAP) machines during the rental to purchase period, which is typically 12 months. Reimbursement for the supplies is included in the reimbursement for the machine. After the rental period, replacement of covered supplies is allowed once per calendar year.

Effective for claims incurred on or after July 1, 2016, supplies for CPAP and BiPAP machines will be covered one time every three months, after the initial 12-month rental to purchase period. Coverage will be subject to plan provisions.

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

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New Reimbursement Methodology for Outpatient Facility Claims

For charges incurred on or after April 1, 2016, HealthChoice and the Department of Corrections (DOC) 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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New Subrogation Administrator

In the event treatment is provided to a HealthChoice member for an injury or illness caused by a third party, the Plan has subrogation rights. Beginning Jan. 1, 2016, the new subrogation administrator for the Office of Management and Enterprise Services Employees Group Insurance Department (EGID) is McAfee & Taft and Healthcare Recovery Solutions (HRS). McAfee & Taft and HRS will be performing all research regarding possible subrogation claims, including but not limited to:

  • Medical claims;
  • Dental claims;
  • Defective medical devices;
  • Dangerous prescription drugs; and/or
  • Toxic exposure.

All Network Providers should be aware that their contract requires them to file claims with HealthChoice. This includes claims for which a third party is responsible. In addition, provider contracts strictly prohibit Network Providers from collecting any amounts from HealthChoice members that are in excess of the Allowable Fees and/or that exceed the member’s deductible and coinsurance liability. The only exception applies to services not covered by the Plan or if annual or lifetime benefit limits have been reached.

More information regarding subrogation can be found in Title 74 of Oklahoma Statutes, Section 1306.1. Subrogation information is also available in the EGID Administrative Rules.

If you have questions about subrogation, please call McAfee & Taft at 1-405-235-9621 or toll-free 1-844-724-9386 between 7:00 a.m. to 6:00 p.m., Monday through Friday, excluding holidays.

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Laboratory Screening and Confirmation Services

Laboratory screening and confirmation services are covered under the HealthChoice health plans, subject to deductible, coinsurance, out-of-pocket maximums, clinical editing and all policy provisions. For charges incurred on or after July 1, 2016, HealthChoice will cover the following presumptive (qualitative) and definitive (quantitative) laboratory urine drug screenings when medically necessary.

  • Presumptive (qualitative) laboratory urine drug screenings are limited to 12 total per calendar year, and certification is not required.

a. 80300 DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES
b. G0477 DRUG TST PRESUMP; CPBL BEING READ DC OPT OBV ONLY
c. G0478 DRUG TEST PRESUMP; READ BY INSTRUM-AST DC OPT OBV
d. 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.

a. G0480 DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CL
b. G0481 DRUG TEST DEFINITV DR ID METH P DAY 8-14 DRUG CL
c. G0482 DRUG TEST DEFINITV DR ID METH P DAY 15-21 DR
d. G0483 DRUG TST DEFINITV DR ID METH P DAY 22/MORE DR CL

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

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Changes to Certification Criteria

Effective July 1, 2016, the certification administrator, APS Healthcare, will utilize the certification criteria developed by InterQual. The requirements and timeframes for certification will remain the same.

If you have questions regarding certification or the change in criteria, contact APS Healthcare. Refer to “Network Provider Contact Information” at the end of this newsletter.

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July Fee Schedule Update Notice

For charges incurred on or after July 1, 2016, HealthChoice and the Department of Corrections (DOC) will update the following fee schedules: quarterly fee schedule addendum and other updates as necessary for CPT/HCPCS, outpatient facility(OP), ambulatory surgery center (ASC), the American Society of Anesthesiologists (ASA), and the American Dental Association (ADA).  Outpatient rates for the procedures covered under the HealthChoice Select Program that became effective April 1, 2016, will be fully phased in beginning July 1, 2016.

Additional Fee Schedule Updates

  • For charges incurred on or after April 1, 2016, HealthChoice and DOC updated the following fee schedules: comprehensive fee schedule update for CPT/ HCPCS, OP, ASC, and ADA.
  • For charges incurred on or after April 1, 2016, HealthChoice and DOC 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.
  • For charges incurred on or after Oct. 1, 2016, HealthChoice and DOC will update the following fee schedules: quarterly fee schedule addendum and other updates as necessary for CPT/HCPCS, OP, ASC, ASA, and ADA.
  • For charges incurred on or after Oct. 1, 2016, HealthChoice and DOC will update the following fee schedules: comprehensive fee schedule update for MS-DRG and MS-DRG LTCH.

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.

As a reminder, the American Medical Association periodically changes, adds, corrects, and/or deletes procedure codes throughout the year. When these changes occur, HealthChoice and DOC review them as soon as possible and make any necessary changes. Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis when necessary.

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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Fee Schedule Legend Updates

Effective April 1, 2016, a reimbursement methodology based on a four-tier system is being utilized for all facilities for which claims are reimbursed under the outpatient fee schedule for HealthChoice and the Department of Corrections (DOC).

 The fee schedules on the HealthChoice and DOC websites at https://gateway.sib.ok.gov/feeschedule/Login.aspx and https://gateway.sib.ok.gov/DOC/FeeSchedule/Login.aspx respectively include a legend that providers will need to reference to identify their tier designations. The tier definitions detailed in the legend are:

  • 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

Facilities are assigned to an urban or rural status as determined by the county in which they operate. Counties designated by the U.S. Census Bureau as a part of a metropolitan core based statistical area (CBSA) are considered urban.

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.

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July 2016 Update to Preventive Services

In 2012, HealthChoice adopted benefits for preventive services that are covered at 100 percent of Allowable Fees for members who meet clinical criteria and use HealthChoice Network Providers. Since that time, benefits have been added and expanded to include additional coverage. The complete list of preventive services can be found at https://www.ok.gov/sib/Preventive_Services.html.

Effective July 1, 2016, the following changes, as indicated in bold, will be made to the preventive services benefits. The beginning numbers relate to the number of the service in the preventive services list on the website.

2. Alcohol Misuse Screening and Behavioral Counseling Interventions — 99408, 99409, G0442, G0443, H0049, males and females ages 18 and older, two total free per calendar year.

6a. Genetic Risk Assessment and BRCA Mutation Testing — Certification required. One total per lifetime. Billing codes: 81211, 81212, 81214, 81215, 81216, 81217, 81218, 81219.

7. Breastfeeding, Primary Care Interventions to Promote — Included in prenatal and postpartum care. Refer to https://www.lalecheleague.org/ for resources and support information.

10. Colorectal Cancer, Screening — 3. Colonoscopy consultations and pathology exams.

17. Hearing Loss in Newborns, Screening — 92551, 92552, 92567, 92586, 92587, ages one or younger; one total free per calendar year.

30. Sickle Cell Disease, Screening — 85660, males and females up to age one; one free per calendar year.

34. Visual Impairment in Children Under Age 5, Screening — 99172, 99173, 99174, males and females up through age four; one total free per calendar year.

39. Pediatric Preventive Health Care “Bright Futures” — Children through age 17; additional benefit — all services on the same date of service as the preventive visit with a preventive service diagnosis. (Services for age 18 years through 19 years no longer covered.)

40. Adult Preventive Exam — Two total per calendar year; ages 18 and older.

41. Well Woman Visit — Ages 17 and under, refer to Pediatric Preventive Health Care “Bright Futures,” 39 above. Ages 18 and older, refer to adult preventive exam, 40 above.

46. Breastfeeding, Support, Supplies and Counseling — Breast pumps, E0602NU, E0602RR, E0603, E0604, female members and dependents will no longer be limited to one total per lifetime. Supplies, A4281, A4282, A4283, A4284, A4285, A4286, female members and dependents will no longer be limited to one each per pregnancy. Refer to https://www.lalecheleague.org/ for resources and support information.

48. Contraceptive Methods and Counseling — 11976, 11981,11982,11983, 58300, 58301, 81025, J1050, J7297, J7298, J7300, J7301, J7306, J7307, S4981, S4989, female members and dependents ages 18 and older, Implantable Rod or IUD one free total every five calendar years. (J7302 is being deleted.)

50. Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low Dose Computed Tomography — Screening counseling, G0296, one total per calendar year for members and dependents ages 55-80. Screening tomography, G0297, S8032, one total per calendar year for members and dependents ages 55-80.

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Infusion Therapy Changes

For all infusion therapy charges incurred on or after March 1, 2016, certified home skilled nursing visits are no longer included in the HealthChoice Allowable Fee, but can be billed separately.  Home health services should be billed by the provider rendering the services.

Please remember that home health nursing services require certification by the HealthChoice Health Care Management Unit (HCMU) to establish medical necessity.

If you have questions regarding the certification process or to request certification, please contact HCMU. 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
  • Health care services certification reviews
  • Certification appeal reviews
  • Cancellations of service reservations
  • Referral reviews
  • Extend certification reviews
  • Reservation of medical services

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 transaction; 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 Change Healthcare, and Change Healthcare 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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Value-Based Reimbursement

The Medicare program is committed to value-based payment, including bundled payment. The Centers for Medicare & Medicaid Services (CMS) launched its Bundled Payments for Care Improvement (BPCI) initiative in 2013, and its Comprehensive Care for Joint Replacement (CJR) initiative will be mandatory for hospitals in the Oklahoma City Metropolitan Statistical Area beginning April 1, 2016. CMS has established a goal of 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018.

HealthChoice intends to be on the leading edge of payment innovation and provider collaboration in order to develop cost-effective models that allow providers to deliver the highest quality care to patients.

By participating in the HealthChoice Select Program, providers have the opportunity to develop sustainable value-based patient care models through improved care management processes and increased efficiency. In doing so, providers can ultimately increase per case net revenue.

Improved care coordination allows providers to align their objectives to deliver value to patients. Providers participating in value-based payment arrangements have reported higher patient satisfaction scores for their patients in bundled arrangements primarily due to enhanced provider-patient engagement.

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Expanded Coverage for Viscosupplementation

For charges incurred on or after Jan. 1, 2016, HealthChoice covers viscosupplementation of the knee under pharmacy benefits, in addition to the coverage provided under medical benefits.

Viscosupplementation of the knee is indicated only for osteoarthritis of the knee and requires prior authorization under pharmacy benefits and certification under medical benefits. Coverage is subject to all plan provisions, certification requirements, and limits on duration/frequency of injections.

For prior authorization under HealthChoice pharmacy benefits, contact CVS/caremark. For certification under HealthChoice medical benefits, contact the HealthChoice Health Care Management Unit. Refer to “Network Provider Contact Information” at the end of this newsletter.

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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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