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The Employees Group Insurance Division (EGID) will have a new third party claims payer, HealthSCOPE Benefits, effective Jan. 1, 2018.
DXC (formerly HPE) will continue to pay claims and answer questions related to services incurred during 2017 and prior until at least June 30, 2018.
Facts about HealthSCOPE Benefits include:
- Fourth largest TPA in the country.
- Paid almost $1.5 billion in claims for approximately 500,000 members in 2016.
- Ninety-seven percent of customer inquiries in 2016 were resolved during the first call.
- Average answer speed in call center is 19.65 seconds.
- Claim turnaround in 2016 averaged 3.57 days.
- Average claims financial accuracy over 99.65 percent.
- HealthSCOPE Benefits currently covers over 5,000 lives in Oklahoma through Adventist Risk Management, Accident Care and Treatment, Owens Corning, OK Foods, SLPT Global Pump, and Fidelity Communications. Other large plans outside of Oklahoma include the State of Nevada and Whirlpool.
- Two employees will be on site at EGID.
- Most work for EGID will be done in Little Rock, AR, and Columbus, OH.
EGID will have specific tracking for provider issues during the transition, and communications to the providers will occur as needed throughout the transition. Be sure to watch for notices via mail and email and check our website frequently for updates.
EGID is dedicated to making this a smooth and seamless transition. Please don’t hesitate to call EGID Network Management with any questions at 405-717-8790 or toll-free 844-804-2642.
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Beginning July 1, 2017, the HealthChoice administrative office moved from the first-floor reception area to a new location on the 6th floor of our current office building. As a result of this move, the physical and mailing address has changed to the following:
EGID
3545 N.W. 58th St., Ste. 600
Oklahoma City, OK 73112
Please make note of the new address.
This does not impact claims. Claims and claims correspondence will continue to be sent to the claims administrator.
For questions about this address change, refer to Network Provider Contact Information at the end of this newsletter.
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Effective July 1, 2017, HealthChoice updated the certification requirements to include all CT scans, MRIs, MRAs, PETC, SPECT, and outpatient pacemaker/defibrillator procedures. For a complete list of CPT/HCPC codes HealthChoice added to the certification list, visit our website at https://www.ok.gov/sib/Providers/HealthChoice_Certifications.html.
If you have questions, please call the certification administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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CPAP-BiPAP
HealthChoice and the Department of Corrections cover supplies for continuous positive airway pressure (CPAP) machines and bi-level positive airway pressure (BiPAP) machines during the rental-to-purchase period, which is 12 months.
Effective July 1, 2017, supplies will be reimbursed separately, subject to plan provisions. During the initial rental-to-purchase period, covered unit supplies are limited to once every three months, not to exceed four per calendar year.
Prior to July 1, 2017, supplies are included in the reimbursement for the machine during the rental period. After the rental period, supplies are allowed once every three months, not to exceed a total of four times per calendar year.
Complex Rehab Technology – Custom Wheelchair
Effective July 1, 2017, custom wheelchairs and accessories may be considered a purchase option based on review and approval from the health care management unit.
Prior to July 1, 2017, HealthChoice and the Department of Corrections cover custom wheelchairs and wheelchair accessories as only a rental-to-purchase option.
If you have questions about DME benefit changes, please contact the claims administrator at 405-416-1800 or toll-free 800-782-5218. For questions about certification, contact the health care management unit at 405-717-8879.
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Due to a change in policy, network providers for HealthChoice, the Department of Corrections and the Department of Rehabilitation Services are no longer required to enroll to receive electronic remittance advices (ERAs) or register for ClaimLink.
Although these are no longer requirements, HealthChoice encourages providers to continue receiving ERAs or enroll in ClaimLink. There are several benefits of choosing ERAs versus paper remittance advices.
- Receive remittances more quickly; i.e., the day the claim finalizes, rather than waiting up to 10 days after the payment was made.
- Reduce paper and printing costs.
- Preserve the environment.
- Reduce administrative costs; i.e., costs associated with staff time to review and file paper remittances.
If you have questions, please call network management. Refer to Network Provider Contact Information at the end of this newsletter.
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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 questions, please contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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For charges incurred on or after July 1, 2017, EGID updated the HealthChoice and the Department of Corrections Select Facility and Ambulatory Surgery Center addendums to require participating facilities to bill covered implants at invoice costs, less any rebates and or discounts received by the facility for all Select services. For charges incurred on or after April 1, 2017, HealthChoice and the Department of Corrections no longer reimburse implants separately on Select inpatient claims as they are inclusive of the MS-DRG.
For more information, refer to the HealthChoice Select Facility Amendment at https://www.ok.gov/sib/documents/HCSelectASCAmendment.pdf.
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Effective July 1, 2017, in the event of an inpatient transfer case, the transfer allowable fee for the transferring facility is calculated for HealthChoice and Department of Corrections as follows: (MS-DRG allowable fee/geometric mean length of stay) x (length of stay + 1 day).
The total transfer allowable fee paid to the transferring facility is capped at the amount of the MS-DRG allowable fee for a non-transfer case. If the receiving facility is also the final discharging facility, HealthChoice allows payment at the MS-DRG allowable fee as if it were an original admission.
If you have questions, please call network management. 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.
You should find Faxback an easy-to-use, convenient method for obtaining HealthChoice member information.
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Charges incurred on or after July 1, 2017, certification for Botox injections, including HCPCS codes J0585, J0586, J0587, and J0588, is only required when administered in a physician office setting place of service 11.
Botox injections administered in an outpatient/ASC setting no longer require certification. Botox injections in both the physician office and outpatient setting are subject to standard reimbursement methodology and plan provisions including deductible, copay, coinsurance and medical necessity.
If you have questions, contact the certification administrator. 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 associated costs. 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.
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 the applicable procedure/service.
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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 from current or previous file updates. 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, a referral coordinator may contact members to help guide them through the HealthChoice Select process. Serving as an advocate throughout the entire process, the referral coordinator’s role is to ensure providers and members have a positive, beneficial experience.
The referral coordinator provides the member and facility an identification document called an e-ticket, which 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 Oct. 1, 2017, HealthChoice and the Department of Corrections (DOC) will make comprehensive updates to the following fee schedules: MS-DRG and MS-DRG LTCH, 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), the American Dental Association (ADA), and Select inpatient and outpatient. Rates for the outpatient procedures covered under the HealthChoice and DOC Select programs that became effective July 1, 2017, will be fully phased in beginning Oct. 1, 2017.
Inpatient and outpatient tier designations are updated annually on Oct. 1 based on the most current CMS fiscal year inpatient prospective payment system (IPPS) impact file for network providers.
Additional Fee Schedule Updates
- For charges incurred on or after July 1, 2017, HealthChoice and DOC made comprehensive updates to the following fee schedules: CPT/ HCPCS, OP, ASC, ADA, and Select inpatient and outpatient.
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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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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For our providers…
The Care Coordination 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 can greatly benefit from this 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 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 working with someone to help them navigate the plan. The requirements for precertification remain the same.
The HealthChoice provider fee schedules, certification, and 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 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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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 PA solution utilized by 70 percent of the pharmacy benefit manager and pharmacies in the marketplace today, which makes CoverMyMeds a one-stop shop for all of your professional PA needs.
CoverMyMeds allows electronic submission of all the necessary information for submitting a PA for a patient, in some cases resulting 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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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 for when the procedure requires 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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In an effort to better serve our providers, the claims administrator added new phone prompts to the HealthChoice local and toll-free numbers that 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. Please have the call reference number and the name of the claims representative who assisted you. If you do not have this, you must 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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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
www.healthchoiceok.com
Medical and Dental Claims
DXC Technology
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 167608
Irving, TX 75016-9826
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
DXC Technology
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
DXC Technology
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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