In This Issue...
Effective
Jan.1, 2018, HealthChoice will have a new third-party administrator,
and with this change, HealthChoice members will receive a new medical
and/or dental ID card. Listed below are a few things providers can do to
make sure they stay informed:
- Check the HealthChoice website at www.healthchoiceok.com/providers frequently for the latest in implementation news.
- HealthChoice sends notifications through email. Make sure you have healthchoiceok@service.govdelivery.com in your contact list.
- Share information.
Keep your business office and practice office updated with any
implementation news that could affect your practice.
HealthChoice
is dedicated to making this a smooth and seamless transition. Please do
not hesitate to call network management with any questions. Refer to
Network Provider Contact Information at the end of this newsletter.
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HealthChoice
will soon offer providers an online form to initiate the certification
process. Beginning Jan. 1, 2018, providers will be able to visit www.healthchoiceconnect.com
and enter the patient, service, provider and facility details. When all
appropriate information is provided for a determination to be made, a
nurse will contact you with the decision. Providers will still be able
to use the current process for certifications; however, using the
website will be more convenient, saves time on the phone, and can help
the process go smoothly.
All
certifications that are initiated in 2017 that will apply to ongoing
services in the 2018 plan year will be provided to the new certification
administrator.
The
current certification administrator will continue to process all
certification requests (including those for 2018 dates of service if
applicable through Dec. 31, 2017).
Additional
information about the certification website will be provided. Please
continue to check the HealthChoice provider website at www.healthchoiceok.com/providers.
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HealthChoice
covers orthodontic services for members under the age of 19; and for
members ages 19 and older with temporomandibular joint dysfunction.
HealthChoice pays 50 percent of allowable fees, and there is no calendar
year deductible or lifetime maximum benefit. A 12-month waiting period
applies to all orthodontic benefits.
Effective
Jan. 1, 2018, HealthChoice is updating the reimbursement policy for
comprehensive orthodontic services. Providers will submit one claim for
the entire inclusive orthodontic course of treatment. The claim must
include the banding date and the length of treatment in months. The
payment for the first month of treatment is one-half of the orthodontic
benefit and the balance is payable in monthly installments over the
remaining length of treatment so long as the patient remains eligible.
Please
note this change only applies to comprehensive orthodontic ADA codes.
There are no changes on the reimbursement policy for unrelated
services.
If you have questions, call network management. Refer to Network Provider Contact Information at the end of this newsletter.
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HealthChoice, Department of Corrections, and Department of Rehabilitation Services are excited to announce they will have a new third-party medical and dental claims administrator effective Jan. 1, 2018. The current claims administrator will continue to pay claims and answer questions related to services incurred during 2017 and prior. Providers should continue to submit claims electronically or on paper utilizing acceptable clearinghouses with payer ID 22521 until Jan. 1, 2018. Claims with dates of service on or after Jan. 1, 2018, should be submitted to the new claims administrator. HealthChoice members will receive new ID cards for the 2018 plan year that will reflect the updated payer ID, phone numbers and claim address for the new TPA.
The new medical and dental claims administrator is the fourth largest TPA in the country, paying almost $1.5 billion in claims for approximately 500,000 members in 2016. Claims turnaround in the same year averaged 3.57 days with 99.65 percent accuracy. Average answer speed in the call center is 19.65 seconds with 97 percent of customer inquiries resolved during the first call. The claims administrator 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.
HealthChoice, Department of Corrections, and Department of Rehabilitation Services will have specific tracking for provider issues during the transition, and communications to providers will occur often. Be sure to watch for notices via mail and email and check our website at www.sib.ok.gov frequently for updates. Providers should share these notices with their registration, scheduling and business office staff.
HealthChoice, Department of Corrections, and Department of Rehabilitation Services are dedicated to making this a smooth and seamless transition. Please do not hesitate to call EGID Network Management with any questions. Refer to Network Provider Contact Information at the end of this newsletter.
CLAIMS WITH DOS PRIOR TO 01/01/18
CURRENT TPA
PHONE
HealthChoice: Toll-free 800-782-5218
Department of Corrections: Toll-free 800-262-7683
Department of Rehabilitation Services: Toll-free 800-944-7938
FAX
405-416-1790
TTY
405-416-1525 or Toll-free 800-941-2160
CLAIMS ADDRESS
HealthChoice
P.O. Box 24870
Oklahoma City, OK 73124-0870
Department of Corrections
P.O. Box 268928
Oklahoma City, OK 73126-8928
Department of Rehabilitation Services
P.O. Box 25069
Oklahoma City, OK 73125-5069
CORRESPONDENCE ADDRESS
HealthChoice, DOC, DRS
P.O. Box 24110
Oklahoma City, OK 73124-0110
PAYER ID
HealthChoice, DOC, DRS: 22521
CLAIMS WITH DOS AFTER 01/01/18
NEW TPA
PHONE
HealthChoice: Toll-free 800-323-4314
Department of Corrections: Toll-free 800-323-3710
Department of Rehabilitation Services: Toll-free 800-285-6815
FAX
Toll-free 800-496-3138
TTY
711 or Toll-free 800-545-8279
CLAIMS ADDRESS
HealthChoice
P.O. Box 99011
Lubbock, TX 79490-9011
Department of Corrections
P.O. Box 16532
Lubbock, TX 79490-6532
Department of Rehabilitation Services
P.O. Box 16485
Lubbock, TX 79490-6485
CORRESPONDENCE ADDRESS
Same as claims address above
PAYER ID
HealthChoice: 71064
Department of Corrections: 71065
Department of Rehabilitation Services: 71065
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HealthChoice Retires Billing Guides
In an effort to align with industry standard practices, EGID will retire the HealthChoice, DOC and DRS billing guides effective Jan. 1, 2018.
HealthChoice, DOC and DRS will recognize all standard ANSI ASC X12N transaction guidelines for services beginning Jan. 1, 2018.
ECHO Health Provider Support Services
Beginning Jan. 1, 2018, ECHO Health will serve as EGID’s health care payment consolidator and provide support for HealthChoice, DOC and DRS EFT and ERA processes. ECHO Health will have a team of 55 dedicated customer service and enrollment support representatives that will provide support.
For additional information about ECHO Health, visit https://www.ok.gov/sib/documents/ECHOProviderSupportServices.pdf.
Although ECHO Health recommends providers register six to eight weeks before go live, providers can begin the registration process immediately at https://view.echohealthinc.com/EFTERA/efterainvitation.aspx.
For additional informaiton or to initiate enrollment, please call ECHO Health toll-free at 888-834.3511.
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For dates of service beginning Jan. 1, 2018, HealthChoice will adopt more industry standard claim editing guidelines. These guidelines are a combination of CMS, CCI, and McKesson claim editing criteria which have been evaluated for implementation based on plan experience.
To ensure our network providers have the best possible experience with our organization, we are excited to announce the launch of our new Advanced Communication Engine system. ACE will be available to all direct submitters as well as those who transmit claims via clearinghouses or billing services. New ACE Edits will appear on claim rejection reports (277CA) as HealthChoice deploys ACE into the claim submission process.
- ACE alerts you to deny certain claims through claim acknowledgement transaction reports with clear instructions on how to fix the error and access the supporting documentation that triggered the alert.
- Claims failing the pre-adjudication editing process are not forwarded to our claims adjudication system.
- ACE integrates into your current EDI workflow so you can modify claims before submission.
- After you have reviewed the ACE Edit, if you choose not to change the claim, you can resubmit in its original format and it will pass directly into our claims adjudication system for processing.
ACE does not require any downloads or changes in your current EDI workflow and is available to you at no cost. Help improve clean claim rates and increase collections with actionable edit intelligence.
Providers should work with their existing clearinghouse or billing service to stress the importance of receiving a full 277CA claim submission report to include the new ACE Edits they will see with the implementation of ACE.
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Did you know that the Employees Group Insurance Division 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.
- Transportation.
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 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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Payments by HealthChoice for non-network services provided in the emergency room setting are identical to those provided for in 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, 2018, when services are rendered in place of service 20 Urgent Care Facility: location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention, the copay will be $30 whether the patient is being seen by a primary care physician or specialist. This change applies to the HealthChoice High and High Alternative Plans and High Deductible Health Plan.
If you have questions, contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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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
-
Providers
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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.
HealthChoice, DOC and DRS are excited to announce call center
improvements under the new TPA. The call center will be staffed by 40
dedicated provider customer service representatives and 20 dedicated
member customer service representatives.
If an overpayment occurs, the new TPA will notify providers in writing of the amount along with the related claim information. If the amount is in excess of $10,000, providers will be contacted by phone as well. If the overpayment is not satisfied within 150 days of the initial request, the TPA will recover funds from another claim or claims from the same tax ID. If the overpayment cannot be satisfied within an additional 30 days, the TPA may use its own resources or those of a third party to recover overpayments. This new process offers providers a substantially longer timeframe to refund the overpayment.
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As stated in the summer edition of the Network News, HealthChoice and the Department of Corrections have updated the following fee schedules for add, change or deleted codes for charges incurred on or after Oct. 1, 2017, CPT/HCPCS, outpatient facility (OP), ambulatory surgery center (ASC), Select inpatient and outpatient codes. The comprehensive fee schedule was updated for MS-DRG, MS-DRG LTCH, inpatient and outpatient bariatric surgery for charges incurred on or after Oct. 1, 2017.
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, and ASC 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 become 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, 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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Beginning Oct. 1, 2017, HealthChoice and the Department of Corrections will no longer require certification for outpatient pacemaker and defibrillator procedures. The certification requirement has been removed for the following outpatient surgical codes.
33206 33207 33208 33210 33211 33212 33213
33214 33216 33217 33218 33220 33221 33224
33226 33227 33228 33229 33230 33231 33233
33240 33241 33249 33262 33263 33264 33270
33271 33282
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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The HealthChoice dental fee schedule was updated on July 1, 2017, to allow ADA codes D0364-D0369 and D0380-D0385 under the health benefit. These codes were previously listed in error as non-covered on the dental fee schedule. This retro update is effective beginning with dates of service Jan. 1, 2017. Dental providers do not need to resubmit claims. If claims were previously denied in error, HealthChoice will automatically adjust these claims.
If you have questions, call the dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
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Effective Oct. 1, 2017, HealthChoice Select can reimburse bilateral procedures at 150 percent of the Select allowable fee when a bilateral modifier is billed on the claim. Appropriate modifiers include:
- Bilateral modifier 50 billed on any code within the claim.
- Both an LT and RT modifier billed on the same claim.
- RC and LC or RC and LM modifier billed on any codes within the claim.
- E1 or E2 and E3 or E4 modifiers billed on any codes within the claim.
- FA or F1-F4 and F5-F9 on any codes within the claim.
- TA or T1-T4 and T5-T9 on any codes within the claim.
Only one bilateral encounter will be reimbursed per claim.
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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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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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, please refer to the HealthChoice Select Facility Amendment at https://www.ok.gov/sib/documents/HCSelectASCAmendment.pdf.
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All HealthChoice and the Department of Corrections contracts contain timely filing provisions and HealthChoice encourages providers to file medical and dental claims within the constraints of their existing provider contracts.
As a courtesy, HealthChoice and the Department of Corrections have historically accepted medical and dental claims for dates of services received no later than the last day of the calendar year immediately following the calendar year in which the service or supply was rendered.
In order to move to a more industry standard time period for claims processing, effective Oct. 1, 2017, HealthChoice and the Department of Corrections will accept claims received no later than 365 days following the date the service or supply was rendered.
Providers are still strongly encouraged to file claims according to the timely filing limits contained within their existing HealthChoice and the Department of Corrections provider contracts. The extension is offered as a courtesy and is subject to change upon future notice.
If you have questions, contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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According to the Internal Revenue Service, the tax identification number, name and address on the W-9 must match the SS4 letter you received from the IRS confirming your TIN. Only one W-9 that applies to all providers who share the TIN should be prepared and sent. The W-9 can only contain one address. A physical address and a mailing address are not to be reported or the W-9 will be returned and backup withholding could occur.
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The certification requirement for scar revision was implemented effective July 1, 2017, for the following outpatient surgical procedure codes.
13100 13101 13102 13120 13121 13122 13131
13132 13133 13152 13153
Effective for charges incurred on or after Oct. 1, 2017, the certification requirement for these codes has been removed.
If you have questions, contact the certification administrator. Refer to Network Provider Contact Information at the bottom of this email.
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Providers should continue to provide all changes related to electronic payments and remittance advices to HealthChoice Network Management to insure receipt of timely payment and related remittance advice information for 2017 and prior years claims.
If you have questions, call HealthChoice Network Management. Refer to Network Provider Contact Information at the end of this newsletter.
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Beginning Jan. 1, 2018, HealthChoice’s new TPA will utilize the Availity Web Portal for Direct Data Entry for submission of claims for HealthChoice, DOC and DRS.
HealthChoice is excited to announce this secure platform will be available to providers for industry standard claims submissions for dates of service beginning Jan. 1, 2018, and later.
Providers will continue to access DXC’s ClaimLink application for all 2017 and prior dates of service. Providers are urged to submit prior year claims for adjudication as soon as possible when services are rendered so they may be adjudicated timely by DXC during the designated run out period.
If you have questions, call network management. 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
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