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Effective with the April 1, 2017, fee schedule updates, HealthChoice made some changes to the appearance of the fee schedule. These updates are now housed within the full file and not listed separately on the addendum file. The full file now contains an add/change/delete column and certification column. The add/change/delete column indicates the changes that occurred from the most recent or previous file update to the current file. Refer to the legend below for examples of what you might see in the add/change/delete column fields.
The certification column indicates a C if a certification for that code is needed. If it is blank, certification is not required. All other fields on the fee schedule remain as they are currently.
If you have questions, please contact network management. For questions about certification, contact the certification administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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The HealthChoice and Department of Corrections (DOC) Select fee schedule has been updated for all services incurred on or after April 1, 2017. 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.
Fee schedule updates are reported in each issue of the Network News distributed quarterly to all network providers. We are sending you this notice as a courtesy informing you the fee schedules will be updated.
If you have questions, please contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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Adding to the already extended wait time at the call center, our claims administrator is receiving a large amount of calls from providers’ collection agencies requesting claim details. As network providers, you should work directly with your collection business partners to provide them the details required in relation to claim payment and remittance advice details. Our claims administrator has been instructed to inform collection agencies they should refer to the remittance advices and then call back if they have questions about them.
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Payments by HealthChoice for non-network services provided in the emergency room setting are identical to those provided for a network setting. If a member is admitted to the hospital through the emergency room, network benefits are applied to the emergency room charges, the services rendered in the emergency room, and all covered inpatient and related ancillary services for the same admission. Non-network providers are permitted to balance bill for the difference between the allowed charges and billed charges. The plan is not responsible for any payments related to balance billing.
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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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Notable changes to the HealthChoice Select Outpatient/ASC Fee Schedule:
- Additional CPT codes have been added to the following types of procedures:
· Arthroscopy
· Nose
· Digestive system
· Pain
· Head/Face
· Radiology/Radiography
· Lithotripsy
· Throat
- Added cleft palate (CP) as a Select type of procedure.
- Increased allowable fees for procedures that include fluoroscopic guidance.
- Elimination of certain granular code combinations and consolidation to a smaller code set where possible.
- Digestive system type of procedure that included a colonoscopy/sigmoidoscopy in the bundled combinations has been duplicated to the colonoscopy/sigmoidoscopy type of procedure.
- Type of procedure changes from Radiology/Radiography to Cardio for certain CPT codes.
- Type of procedure change from PET to Cardio for CPT code 78459.
Also, we are excited that with the April 1, 2017, fee schedule updates, HealthChoice has made some changes to the appearance of the fee schedule. These updates are now housed within the full file and not listed separately on the addendum file. The full file now contains an add/change/delete column and certification column. The add/change/delete column indicates the changes that have occurred from the most recent or previous file update to the current file. Refer to the legend below for examples of what you might see in the add/change/delete column fields.
For Select, the legend is a little different:
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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.
If you would like to speak to a referral coordinator, please contact the Redirection team at toll-free 844-464-4276.
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For charges incurred on or after July 1, 2017, HealthChoice and the Department of Corrections (DOC) may 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), Select, and the American Dental Association (ADA). Outpatient rates for the procedures covered under the HealthChoice Select program that became effective April 1, 2017, will be fully phased in beginning July 1, 2017.
Additional Fee Schedule Updates
- For charges incurred on or after April 1, 2017, HealthChoice and DOC updated the following fee schedules: comprehensive fee schedule update for CPT/ HCPCS, OP, ASC, Select and ADA.
- For charges incurred on or after April 1, 2016, HealthChoice and DOC adopted a new reimbursement methodology for outpatient facility claims. For charges incurred on or after April 1, 2017, phase 2 was implemented for the outpatient reimbursement methodology. 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, 2017, HealthChoice and DOC may update the following fee schedules: quarterly fee schedule addendum and other updates as necessary for CPT/HCPCS, OP, ASC, ASA, Select, and ADA.
- For charges incurred on or after Oct. 1, 2017, HealthChoice and DOC may 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.
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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 HealthChoice High Deductible Health Plan must meet their deductible before any benefits, other than preventive services, are paid by the plan.
STEP 1 A member’s physician identifies a need for a service or procedure.
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
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.
STEP 4 The HealthChoice Select facility will contact the member to schedule the appointment for applicable procedure/service.
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For our providers…
HealthChoice is excited to announce our new care coordination program. This program is available only to pre-Medicare former employees and surviving dependents enrolled in a HealthChoice health insurance plan, which includes approximately 8,600 lives. Members with chronic conditions will greatly benefit from this new program; however, any member who needs information about a condition or assistance navigating to the right providers to meet their individual health care needs will also benefit.
How does care coordination work?
Members who have chronic conditions such as diabetes or pre-diabetes, hypertension, cardiovascular disease, asthma, COPD, hyperlipidemia, or have recently been hospitalized for any related condition are eligible to participate in the HealthChoice Care Coordination program.
Care coordinators will work with providers and caregivers to develop a treatment plan effectively utilizing their benefits.
How does a provider become involved in care coordination?
If the clinical history identifies a high-risk candidate for care coordination (three or more chronic conditions mentioned above), the member will be contacted by our care coordination staff. Following an introduction and enrollment into the HealthChoice Care Coordination program, the member will be required to select a primary care physician (PCP) who will monitor their care and be a resource to ensure they get the appropriate care at the appropriate time. PCPs can be selected from any HealthChoice family practice, general practice, or internal medicine physician. The care coordinator can also assign a PCP to the member if desired and requested. The PCP will then be contacted to gain insight into the treatment plan and anticipated outcomes, with the goal of establishing a relationship that will improve access, communications and compliance.
Members can visit a participating specialist without going through their PCP, but they are encouraged to go through their PCP, if possible, to ensure the PCP is aware of the care they may need so that they can assist in coordinating that care. The member’s PCP should direct them to a network specialist in order to maximize their benefits whenever possible. This also helps prevent duplication of services.
Benefits are not impacted when members participate in the care coordination program. Members will receive information on how to better utilize their benefits by working with someone to help them navigate the plan. The requirements for precertification remain the same.
The HealthChoice provider fee schedules, certification, claims submission, and payment processes will remain in place. Contact HealthChoice for any address updates or practice changes.
Visit www.hccarecoordination.com for more information on this new program including 24/7 nurse advice line, care coordination details, frequently asked questions, health-related articles, health risk assessments and more. If you have questions, please call 405-652-1041 or toll-free 855-445-1471.
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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 requires a scan sheet 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 are available 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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HealthChoice providers have the ability to immediately receive current plan information as well as member eligibility, deductible and out-of-pocket maximum information by fax. This option is available through Faxback. Faxback allows you to enter your fax number and request information be faxed directly to your office.
Faxback documents include:
- Cover sheet.
- Summary of benefits for the member's plan.
- Accumulators for the member's plan.
- Certification requirements.
Faxback is available 24/7.
To access Faxback, contact the medical and dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Please have the following information available before placing your call:
- Your 10-digit NPI number or 9-digit Social Security number.
- Your fax number.
- Member's identification number.
- Member's date of birth.
We hope our providers will find Faxback an easy-to-use, convenient method for obtaining HealthChoice member information.
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A cochlear implant can be a covered benefit by most HealthChoice plans. Network services for this implant and processor are readily available and very cost effective to HealthChoice members. Non-network services for this implant and processor can be very costly. Using an implant and processor made by a non-network manufacturer can be very costly, as it leaves the HealthChoice member responsible for non-network replacement parts and upgrades. Providers must obtain certification for a replacement or upgrade to the processor or if the procedure is going to require an inpatient hospital stay.
The following network provider can assist with questions regarding network implants and processors:
Sunmed Medical Systems
36 W. Route 70, Ste. 214
Marlton, NJ 08053-3024
Phone 856-797-4384
Fax 856-998-4663
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.
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HealthChoice Select is a program designed to reduce the costs of certain services. This is achieved 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.
Under the Affordable Care Act (ACA) preventive services are covered at 100 percent with no copay or deductibles. Effective July 1, 2016, certain screening AND diagnostic mammography procedures are covered at 100 percent under the Select program when provided at a participating Select facility. The CPT codes included in the Breast Service Type are listed below. The facilities that participate in the Select program can be found on the HealthChoice website at https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx.
Please note that all procedure codes are subject to change.
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In an effort to better serve our providers, the claims administrator has added additional phone prompts to the HealthChoice local and toll-free numbers. The additional prompts include options for the Department of Rehabilitation Services and the Department of Corrections.
The claims administrator is the first point of contact for all eligibility, benefits, claim inquiries, 1099 inquiries, etc. Network management is the first point of contact for any contract inquiries.
If you need additional assistance after speaking with the claims administrator, you can call network management. When calling network management, have the call reference number and the name of the claims representative who assisted you. If you do not have this, we will ask that you call the claims administrator again for assistance.
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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HealthChoice and the Department of Corrections cover ostomy bags and wafers under both the medical and pharmacy benefits for charges incurred on or after Oct. 1, 2016. Until Oct. 1, ostomy bags and wafers were covered under only the pharmacy benefit. Ostomy supplies are subject to policy provisions and do not require certification.
If you have questions about coverage of ostomy bags and wafers, please contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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To make corrections to a claim you have already submitted on a CMS-1500, you must resubmit your claim on paper. Corrected CMS-1500 claim forms should not be submitted electronically. Make certain paper claims are clearly marked “Corrected Claims” and sent to:
ES Administrative Services, LLC
P.O. Box 24110
Oklahoma City, OK 73124
Corrections to facility claims filed on UB-04 forms may be submitted to the above ES Administrative Services address or via the 837I electronic process.
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Home sleep studies billed on a CMS-1500 form should be billed with place of service 12. Place of service 12 is for a location other than a hospital or other facility where the patient receives care in a private residence. Claims for home sleep studies billed on a CMS-1500 without place of service 12 are denied with explanation code 6LC, location/procedure mismatch.
If you have any 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, 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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In the Network News Winter Edition 2017, providers were notified that they will have to sign up to receive remittance advices either through an EDI 835 transaction to receive electronic remittance advices
(ERAs) or through the secure web portal, ClaimLink, by Jan. 1, 2017. The requirement for receiving remittance advices electronically has been postponed. When the effective date has been determined, providers will be notified through the Network News, email notification, or mail.
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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Current and Pre-Medicare Members
Effective 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 new deductible applies to pharmacy medications only and members will have to meet this deductible before the normal HealthChoice copay structure applies.
HealthChoice also implemented the HealthChoice Preventive Medication List effective Jan. 1 for all
non-Medicare Part D plans that have a pharmacy deductible, which includes the HealthChoice High and High Alternative Health Plans, and the HealthChoice High Deductible Health Plan. This is a list of generic medications that are not subject to a pharmacy deductible and pay at the normal generic copay level of up to $10 for a 30-day supply or up to $25 for a 90-day supply. This list can be accessed at https://www.ok.gov/sib/documents/HCPreventiveMedicationList.pdf.
Medicare Part D Members
Effective Jan. 1, members on the HealthChoice SilverScript High Option Medicare Supplement Plan have a $100 per person pharmacy deductible. This new deductible applies to pharmacy medications only and members will have to meet this deductible before the HealthChoice SilverScript High Option copay structure applies.
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HealthChoice covers 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. During the rental period, only one set of supplies are covered. After the rental period, replacement of covered supplies is allowed once every three months. Reimbursement for supplies is included in the reimbursement for the machine.
Prior to July 1, 2016, replacement of covered supplies for CPAP and BiPAP were covered once per calendar year after the rental period.
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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CVS/caremark and CoverMyMeds automate the prior authorization (PA) process making it faster and easier for you to review, complete and track PAs. CoverMyMeds is a free electronic prior authorization (ePA) solution utilized by 70 percent of the pharmacy benefit managers and pharmacies in the marketplace today, which makes CoverMyMeds a one-stop shop for all of your practice’s PA needs.
CoverMyMeds allows electronic submission of all the necessary information for submitting a PA for a patient, and in some cases results in automatic approval of the PA in minutes, instead of hours or days.
Create a free account at www.covermymeds.com to start submitting and tracking your PAs online today.
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HealthChoice Providers
www.healthchoiceok.com
Medical and Dental Claims
ES 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
ES 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
ES Administrative Services, LLC
P.O. Box 25069
Oklahoma City, OK 73125-0069
Toll-free 800-944-7938
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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