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Effective Jan. 1, 2017, the Employees Group Insurance Department discontinued the HealthChoice FOCUS health plan. If you have a patient who was 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 ended Dec. 31, 2016.
Effective Jan. 1, 2017, HealthChoice discontinued the $200 incentive payment for the HelpCheck program. HealthChoice continues 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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For charges beginning Jan. 1, 2017, HealthChoice expanded the surgical procedures requiring certification at outpatient facilities to include certain cervical, lumbar and thoracic surgical procedures.
Certification is required within three working days prior to scheduled hospital admissions, specific surgical procedures in an outpatient facility and specific diagnostic imaging procedures, or within one day following emergency/urgent care services. Failure to certify within this timeframe will result in a 10 percent penalty for approved services. If certification is initiated and denied either before or after services are performed, the claim is denied.
The certification administrator will provide active redirection beginning Jan. 3, 2017. HealthChoice Select will add this new redirection feature 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. The referral coordinator’s role is to ensure providers and members have a positive, beneficial experience. The HealthChoice Select program is designed to reduce the costs of select services by contracting with medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs. Services are covered at 100 percent of the bundled allowable fee with no out-of-pocket cost to members when received on the date the surgery or procedure is performed at a HealthChoice Select facility.
For additional information on certification requirements, please review the provider manual located at https://www.ok.gov/sib/Providers/Provider_Manual/index.html or call the certification administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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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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With the departure of Carol Bowman at the end of 2016, some changes have been made to contact information for HealthChoice:
- For general claim issues, contact the medical and dental claims administrator at 405-416-1800 or toll-free 800-782-5218.
- For unresolved provider and Select issues, contact Teresa South, Director of EGID Network Management by email at Teresa.South@omes.ok.gov or by phone at 405-717-8627 or toll-free 844-804-2642
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Effective Jan. 1, 2017, HealthChoice changed 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, HealthChoice no longer covers the following ADA billing codes. These incidental procedures are considered as part of the providers’ write-off.
- D9210 - local anesthesia not in conjunction with operative or surgical procedures.
- D9211 - regional block anesthesia.
- D9212 - trigeminal division block anesthesia.
If you have questions, please contact the dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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HealthChoice has increased 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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Providers will receive one 1099 for each tax identification number (TIN), even when the TIN is shared with other providers. 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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HealthChoice no longer requires an authorization for viscosupplementation injections HCPCS codes J7321, J7323, J7323, J7324, J7325, J7326, and J7237 when billed under the medical plan. Please note the codes included are subject to change. If you have any questions, contact the Health Care Management Unit. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Jan. 1, 2017, HealthChoice allows 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 reflect the accurate copay amount.
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Effective Jan.1, 2017, bariatric surgery is 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 an accredited, participating network Metabolic Bariatric Surgery Accreditation and Quality Improvement Program Comprehensive Center.
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Beginning Oct. 17, 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. 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://www.ok.gov/sib/documents/MedicalRecordsScanForm.pdf.
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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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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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. Services are covered at 100 percent of the bundled allowable fee with no out-of-pocket costs to members when received on the date the surgery or procedure is performed at HealthChoice Select facilities.
Members of the High Deductible Health Plan must meet their deductible before any benefits, other than preventive services, are paid by the plan.
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STEP 1 A member’s physician identifies a need for a service or procedure.
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STEP 2 Members can call the HealthChoice Select Referral Coordinator toll-free at 844-464-4276 or visit the HealthChoice Select provider search page at the web address below to determine if the service is available from a HealthChoice Select provider. https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx
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STEP 3 The HealthChoice Select Referral Coordinator will assist the member in locating a HealthChoice Select facility and provide the member with an e-ticket to take to their appointment.
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STEP 4 The HealthChoice Select facility will contact the member to schedule the appointment for applicable procedure/service.
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Current and Pre-Medicare Members
Starting Jan. 1, members on the HealthChoice High and High Alternative plans have a $100 per person pharmacy deductible with a $300 maximum per family. This deductible is for pharmacy only and members will have to meet this deductible before the normal HealthChoice copay structure applies.
HealthChoice also implemented the HealthChoice Preventive Medication List 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 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 are subject to a $100 per person pharmacy deductible. This deductible is for pharmacy only and members have to meet this deductible before the HealthChoice SilverScript High Option copay structure applies.
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Effective Jan. 1, HealthChoice 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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HealthChoice Select added 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 serves 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 provided to the member and facility from a referral coordinator. The e-ticket contains all the relevant registration information and serves as confirmation to schedule a Select service, but is not required to access a Select facility.
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On Nov. 1, 2016, HealthChoice began contracting with board-certified behavioral analysts and board-certified assistant behavioral analysts. In order to contract with HealthChoice, the provider will need to complete a Uniform Credentialing Application (UCA) and return it with the required attachments as indicated in the Network Provider Contract. A signed copy of the contract signature page will also need to be submitted.
HealthChoice will request, upon receipt of the first claim each rolling year, a proposed treatment plan with a script from the diagnosing professional who diagnosed the autism spectrum disorder.
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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On Jan. 1, 2017, 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, 2017.
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 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:
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Feb. 1: Add, change and delete codes for ASA
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April 1: Comprehensive fee schedule update for CPT/HCPCS, OP, ASC, Select 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.
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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In a continued effort to increase security and privacy of personal information, the Office of Management and Enterprise Services Employees Group Insurance Department (EGID) is requiring all providers to receive electronic remittance advices (ERAs) through an EDI 835 transaction or through the secure web portal, ClaimLink. Network providers for HealthChoice, the Department of Corrections and the Department of Rehabilitation Services were required to enroll for ERAs or register for ClaimLink by Jan. 1, 2017.
EDI 835
Enrollment forms for ERAs are available on the website at http://ok.gov/sib/Providers/Electronic_Remittance_Advice_(ERA)/index.html. If you need additional assistance, 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.
ClaimLink
Registration for ClaimLink is available on the ClaimLink provider page. You can access ClaimLink through the EGID website. Once you have accessed the Provider Page, select the Register Now button located under Log In to start the registration process. Also available is Registration Help located at the bottom
of the page. If you need additional assistance, call the medical and dental claims administrator. Refer to Network Provider Contact Information on the back page. Please have the following information available when calling:
- Your tax identification number associated with the PIN you are registering.
- Your ten-digit NPI number or SSN (provider ID).
- Your provider identification number (PIN) which can be found on each remittance advice or by contacting the claims administrator.
In order for this process to go as smoothly as possible and to avoid delays, EGID is asking network providers not currently participating in EDI 835 or ClaimLink to enroll or register now.
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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
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
Redirection
P.O. Box 42096
Oklahoma City, OK 73123-1755
Toll-free 844-464-4276
Fax 806-473-2762
HealthChoice Network Management
OKC Area 405-717-8790
Toll-free 844-804-2642
Subrogation Administrator
McAfee & Taft
Toll-free 800-235-9621
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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Please share the Network News with:
- Office managers
- Referral and certification staff
- Business office staff
- Front office staff
- Medical records staff
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Providers
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