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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 will require all providers to receive remittance advices electronically by Jan. 1, 2017. To avoid delays, you can enroll or register now to receive your remittance advices electronically.
You have the option to enroll for EDI 835 transaction set, otherwise known as an ERA – electronic remittance advice. The 835 is an electronic version of your explanation of payment. ERA Enrollment forms for network providers are available on the website at https://www.ok.gov/sib/Providers/Electronic_Remittance_Advice_(ERA)/index.html. If you need additional assistance with enrolling in 835 transactions, contact EGID 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.
You also have the option to view ERAs through ClaimLink, our powerful, secure website. ClaimLink also allows you to quickly enter claims, request dental predeterminations, and check eligibility and claims status. Registration for ClaimLink is quick, easy and secure. To access ClaimLink, select ClaimLink for Providers from the drop-down menu under ClaimLink in the top menu bar.
To register, you need to have the following information available:
- Your 10-digit NPI number or your SSN (provider ID).
- Your provider identification number. To find your PIN, access your records by selecting Provider Self Service in the drop-down menu under Providers in the top menu bar. Your PIN number is also located on each Remittance Advice.
- A valid claim number issued by the medical and dental claims administrator and processed under the appropriate PIN.
After you complete your initial registration, you will be asked to create your own unique username and password.
Once you register as a provider, you can create delegates. For information on how to create a delegate, navigate to FAQs at the bottom of the ClaimLink home page. Your delegate will create a four-digit code like the last four digits of the delegate’s driver’s license or another four-digit code chosen by the user. The delegate code is assigned after you register for ClaimLink.
If you have questions regarding ClaimLink or need assistance registering, please contact the medical and dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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Beginning in the fourth quarter of 2016, in an effort to decrease the claims administration turnaround time, the medical and dental claims administrator for HealthChoice, the Department of Corrections and the Department of Rehabilitation Services will begin requiring a scan sheet to be attached to all medical or dental records submitted. This requirement is 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 they are requested by the claims administrator. This scan sheet and instructions for completion are available on our website. A separate scan sheet must be completed for each claim for which you are submitting records.
The form and instructions can be found on our website at https://www.ok.gov/sib/Providers/Medical_Records_Requests/index.html.
If you have questions, please contact the medical and dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Jan. 1, 2017, the Employees Group Insurance Department will discontinue the HealthChoice FOCUS health plan. If you have a patient on the HealthChoice FOCUS plan, please verify their new coverage beginning Jan. 1. Contact our medical claims administrator to verify benefits and eligibility.
HealthChoice conducted a three-year pilot to test the efficacy of the MedEncentive Information Therapy Program in a comparison group analysis. The pilot will end Dec. 31, 2016.
Effective Jan. 1, HealthChoice will discontinue the $200 incentive payment for the HelpCheck program. HealthChoice will continue to cover the preventive visit at 100 percent of the allowable fee as documented. Visit the HealthChoice website at https://ok.gov/sib/Preventive_Services.html for a complete list of preventive services.
If you have questions, please contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Jan. 1, 2017, HealthChoice will allow the billed charges or allowable fees, whichever is less, of the set copay up to the out-of-pocket maximum. All provider remittances and 835 transactions will reflect the accurate copay amount.
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Effective Oct. 1, 2016, all HealthChoice health plans, excluding HealthChoice Medicare Supplement plans, require certification through the HealthChoice Health Care Management Unit (HCMU) for mental health and substance use disorder services that exceed 20 visits per calendar year. The previous requirement was 15 visits.
If you have questions about these certifications, please contact HCMU. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Jan. 1, 2017, HealthChoice will change the reimbursement for preventive services billed with place of service 03-school/educational and 18-worksite/place of employment. These services will be paid the allowable of $51.00 for the following preventive visit codes:
- 99385 INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS
- 99386 INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS
- 99387 INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS&>
- 99395 PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS
- 99396 PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS
- 99397 PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER
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Beginning Jan.1, 2017, bariatric surgery will be a covered benefit under the HealthChoice High, High Alternative, Basic, and Basic Alternative health plans and High Deductible Health Plan for members ages 18 and older. The member must have been covered under a HealthChoice health plan for 12 consecutive months prior to bariatric surgery. Members are encouraged to continue coverage with a HealthChoice health plan for 24 consecutive months after bariatric surgery. Coverage is limited to bariatric sleeve, bypass and duodenal switch as well as revision and conversions. Bariatric services are subject to certification as set forth by the certification administrator and standard benefits and policy provisions apply. All bariatric surgeries must be obtained from a participating network Metabolic Bariatric Surgery Accreditation and Quality Improvement Program Comprehensive Center of Excellence.
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For all charges incurred on or after Jan. 1, 2017, HealthChoice will expand the surgical procedures requiring certification at outpatient facilities to include certain cervical, lumbar and thoracic surgical procedures.
To request certification or if you have questions, contact the certification administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Jan. 1, 2017, HealthChoice and the Department of Corrections will change the conversion factor for anesthesia from $55 to $60 for MD and DO anesthesiologists and from $50 to $55 for APRN-CRNAs.
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HealthChoice is increasing the emergency room copay from $100 to $200 for charges incurred on or after Jan. 1, 2017. The copay will be waived for HealthChoice High, High Alternative and High Deductible Health Plan members if the patient is admitted or if death occurs.
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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In an effort to improve security on our online web portal, ClaimLink, and in support of our mandatory electronic remittances, there will be some changes to the registration process and to existing registered accounts. Current ClaimLink registrants will be emailed a notice requesting they log in to verify and update some of their information.
Please contact our medical and dental claims administrator if you have any questions. Refer to Network Provider Contact Information at the end of this newsletter. ClaimLink can be accessed by visiting our website at https://www.ok.gov/sib/ClaimLink/ClaimLink_for_Providers/index.html.
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The Department of Corrections Network Management post office box has changed to P.O. Box 57630, Oklahoma City, OK 73157-7630. The claims remittance address did not change. Providers should continue sending all claims to HP Administrative Services, P.O. Box 268928, Oklahoma City, OK 73126-8928.
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HealthChoice Select will add this new feature beginning Jan. 3, in an effort to connect members with a HealthChoice Select facility. Members may be contacted by a referral coordinator to help guide them through the HealthChoice Select process. A referral coordinator will serve as the advocate throughout the entire process. The referral coordinator’s role is to ensure providers and members have a positive, beneficial experience.
An e-ticket is a member and facility identification document that will be provided to the member and facility from a referral coordinator. The e-ticket contains all the relevant registration information and will serve as confirmation to schedule a Select service, but is not required to access a Select facility.
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Current and Pre-Medicare Members
Starting Jan. 1, members on the HealthChoice High and High Alternative plans will have a $100 per person pharmacy deductible with a $300 maximum per family. This deductible will be for pharmacy only and members will have to meet this deductible before the normal HealthChoice copay structure applies.
HealthChoice will also be implementing the HealthChoice Preventive Medication List starting Jan. 1 for all non-Medicare Part D plans that have a pharmacy deductible, which includes the High and High Alternative plans and High Deductible Health Plan. This is an expanded list of generic medications that will bypass the deductible and pay at the normal generic copay level of up to $10 for a 30-day supply and up to $25 for a 90-day supply. The list can be accessed at https://www.ok.gov/sib/documents/HCPreventiveMedicationList.pdf.
Medicare Part D Members
Beginning Jan. 1, members on the HealthChoice SilverScript High Option Medicare Supplement Plan will be subject to a $100 per person pharmacy deductible. This deductible will be for pharmacy only and members will have to meet this deductible before the HealthChoice SilverScript High Option copay structure applies.
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Effective Jan. 1, HealthChoice has made formulary changes within several therapeutic categories. As a HealthChoice provider, we encourage the prescribing of generics as the first line of therapy in order to help manage health care costs. Following is the 2017 Excluded Medications List, which is not an inclusive list. This list represents brand products in CAPS, branded generics in upper and lowercase italics, and generic products in lowercase italics.
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The HealthChoice and Department of Corrections (DOC) 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/rural as contained within the current year’s final IPPS file.
For charges incurred on and after Oct. 1, 2016, the following changes are effective for HealthChoice and DOC MS-DRG fee schedules:
MS-DRG
The market basket update factor is 2.7 percent.
The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2017.
MS-DRG LTCH
For charges incurred on and after Oct. 1, 2016, the following changes are effective for HealthChoice and DOC MS-DRG LTCH fee schedules:
- Version 34 of the MS-DRG LTCH fee schedule has a base rate of $52,140.00. The outlier threshold is $21,943.00 and the cost-to-charge ratio is 0.242.
The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2017.
If you have any questions regarding these adjustments, please contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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Did you know that the Employees Group Insurance Department also maintains the Oklahoma Department of Rehabilitation Services 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.
- Tranportation.
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.
For more information, please visit our network provider home page at https://gateway.sib.ok.gov/DRS, email network management at EGID.DRSNetworkManagement@omes.ok.gov or call us. Refer to Network Provider Contact Information at the end of this newsletter.
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As stated in the summer edition of the Network News, HealthChoice and the Department of Corrections (DOC) have updated their fee schedules for CPT/HCPCS, outpatient facility (OP), ambulatory surgery center (ASC), American Society of Anesthesiologists (ASA), American Dental Association (ADA), MS-DRG and MS-DRG LTCH codes effective for charges incurred on or after Oct. 1, 2016.
Inpatient and outpatient tier designations are updated Oct. 1 each year, based on the most current CMS fiscal year inpatient prospective payment system (IPPS) impact file for network providers.
Be aware that HealthChoice and DOC update the CPT/HCPCS, outpatient hospital, ASC, ASA, and ADA fee schedules quarterly.
The next quarterly fee schedule update will be for charges incurred on or after Jan. 1 for CPT/HCPCS, OP, ASC, ASA, ADA and Select inpatient and outpatient fee schedules.
Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the Select program will be fully phased in during the next quarterly update.
The American Medical Association may periodically change, add or delete procedure codes throughout the year. When these modifications occur, HealthChoice and DOC will review the fee schedules as soon as possible and make any necessary changes. Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis when needed.
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. You can also email us at EGID.NetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov.
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For charges incurred on or after July 1, 2016, HealthChoice requires the modifier "ZB" to be appended to HCPCS code Q5102 (Injection, Infliximab).
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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For all charges incurred on or after July 1, 2016, HealthChoice and the Department of Corrections began reimbursing Select bilateral procedures at 150 percent of the Select allowable fee, subject to plan policy and provisions, when billed appropriately. HealthChoice and DOC also began paying combinations of multiple CPT/HCPCS codes as specified within the Select Fee Schedule.
If you have any questions, please contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
Customer Service and Claims
OKC Area 405-416-1800
Toll-free 800-782-5218
FAX 405-416-1790
TDD 405-416-1525
Toll-free TDD 800-941-2160
Pharmacy
CVS/caremark
Pharmacy Prior Authorization Request
Toll-free 800-294-5979
Pharmacy Prior Authorization Request – SilverScript (Part D)
Toll-free 855-344-0930
Certification
APS Healthcare
P.O. Box 700005
Oklahoma City, OK 73107-0005
Toll-free 800-848-8121
Toll-free TDD 877-267-6367
FAX 405-416-1755
HealthChoice Health Care Management Unit
OKC Area 405-717-8879
Toll-free 800-543-6044, ext. 8879
HealthChoice Network Management
OKC Area 405-717-8790
Toll-free 844-804-2642
OKC Area 405-717-8750
Toll-free 866-573-8462
DOC Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 268928
Oklahoma City, OK 73126-8928
Toll-free 800-262-7683
OKC Area 405-717-8921
Toll-free 888-835-6919
DRS Medical and Dental Claims
HP Administrative Services, LLC
P.O. Box 25069
Oklahoma City, OK 73125-0069
Toll-free 800-944-7938
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- Office managers
- Referral and certification staff
- Business office staff
- Front office staff
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Providers
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