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Effective Jan. 1, 2018, HealthChoice is partnering with ECHO Health, a payment disbursement service. ECHO Health is an industry leader in payment administration, and is working very closely with HealthChoice to ensure a smooth transition.
If your organization currently receives paper remittance advices in the mail, you will no longer receive these for claims with dates of service beginning Jan. 1, 2018.
If your organization currently receives electronic fund transfer (EFT) payments from HealthChoice, ECHO Health will continue to utilize that existing EFT information to disburse funds for your organization’s TIN, including all affiliated NPIs and locations. All payment information, explanations of provider payment (EPPs), and electronic remittance advices (ERA) will be available at ECHO Health’s multi-payer portal www.providerpayments.com.
Providers receive the following EFT/ERA services currently available for HealthChoice at no cost:
- EFT payments (made according to your current enrollment on file with EGID).
- Accessing ERAs for download from www.providerpayments.com.
- ERA routing to your designated clearinghouse.
To receive your ERA through your clearinghouse, please refer to information below.
- Daily payment disbursement.
- Payment issuance email notifications (set up through www.providerpayments.com).
- Accessing RAs for download from provider self-service at www.healthchoiceconnect.com.
Please note existing EFT’s and clearinghouses ERA delivery preferences for dates of service in 2018 will be maintained by ECHO Health.
HealthChoice encourages providers and facilities to reach out to ECHO Health Customer Service toll-free at 844-586-7463 if your organization:
Does not currently have access to ECHO Health’s provider portal, www.providerpayments.com.
Would like to automate the ERA delivery through your preferred clearinghouse partner. Please note that if existing clearinghouse routing is in place, this will be maintained.
Claims for Dates of Service Prior to Jan. 1, 2018
You will continue to receive payments and related remittance advices according to your current directive with HealthChoice for claims processed by the current TPA for dates of service prior to Jan. 1, 2018.
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Effective Jan. 1, 2018, HealthChoice’s new TPA is utilizing 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 is 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, 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.
For charges incurred on or after Jan. 1, 2018, the following services have been added to the HealthChoice list of outpatient surgical procedures requiring certification through the HealthChoice certification manager.
Sleep apnea related surgeries, limited to:
- Radiofrequency ablation (coblation, somnoplasty).
- Uvulopalatopharyngoplasty (UPPP), including laser-assisted procedure.
- Septoplasty.
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.
Certification is required within three working days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures, or within one day following emergency/urgent services. If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10 percent penalty is applied. The member is not responsible for this 10 percent penalty. If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied.
Beginning Jan. 1, 2018, there is a new process for all certification reviews related to services rendered or certification decisions made in 2017. To appeal decisions or request a retrospective certification for a date of service prior to 2018:
- Fax retrospective certification requests to 405-717-8947, Attn: HealthChoice 2017 Retro Cert Request.
- Fax appeal requests for denied services to 405-717-8947, Attn: HealthChoice Medical Director.
Requests must:
- Clearly state the provider of service, type of service, and dates of service for the retrospective request and/or appeal.
- Include requester’s contact name, phone and fax number.
- Include all pertinent medical records to justify the medical necessity of the request.
Appeals must:
- Include a detailed letter of medical necessity from the treating provider with supporting documentation.
- Include claim number of any denied claims.
The review process will be completed or a request for additional information will be sent to the requestor via fax within 10 business days. If a retrospective certification is approved, claim(s) should be billed as a corrected claim. The provider will need to include the new certification number and resubmit to the appropriate TPA for reprocessing based on the date of service. If an appeal is approved, the claim will be routed internally to the appropriate TPA for reprocessing. If a retrospective certification or an appeal is denied, a letter will be sent advising you of this decision and what other options may be available.
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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 has updated 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 applies only to comprehensive orthodontic ADA codes. There are no changes on the reimbursement policy for unrelated services.
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.
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All claims for inpatient services that span the 2017 plan year into the 2018 plan year will be processed by the previous TPA.
All outpatient and professional claims should be submitted to the appropriate TPA according to the dates the services were rendered, i.e., the previous TPA (2017 DOS) or the new TPA (2018 DOS). Dates of service for 2017 and 2018 should not be combined on the same claim form. The claims addresses and payer ID numbers for HealthChoice are:
Previous TPA:
P.O. Box 24870
Oklahoma City, OK 73124-0870
Payer ID 22521
New TPA:
P.O. Box 99011
Lubbock, TX 79490-9011
Payer ID 71064
Please visit https://www.ok.gov/sib/Providers/New_Medical_and_Dental_Claims_Administrator.html for Department of Corrections and Department of Rehabilitation Services claims addresses and payer IDs. This information is also provided in the Network Provider Contact Information at the end of this newsletter.
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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 is $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.
HealthChoice, Department of Corrections, and Department of Rehabilitation Services are excited to announce they have a new third-party medical and dental claims administrator. The previous claims administrator will continue to pay claims and answer questions related to services incurred during 2017 and prior. 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, DOC, and DRS are dedicated to making this a smooth and seamless transition. Please do not hesitate to call EGID Network Management with any questions at 405-717-8790 or toll-free 800-543-6044.
Notable Changes
CLAIMS WITH DOS PRIOR TO 01/01/18
PREVIOUS TPA
PHONE
HealthChoice Toll-free 800-782-5218
DOC Toll-free 800-262-7683
DRS 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
DOC
P.O. Box 268928
Oklahoma City, OK 73126-8928
DRS
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 01/01/18 AND AFTER
NEW TPA
PHONE
HealthChoice Toll-free 800-323-4314
DOC Toll-free 800-323-3710
DRS 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
DOC
P.O. Box 16532
Lubbock, TX 79490-6532
DRS
P.O. Box 16485
Lubbock, TX 79490-6485
APPEALS AND PROVIDER INQUIRIES
HealthChoice
P.O. Box 3897
Little Rock, AR 72203-3897
DOC
Same as claims address above
DRS
Same as claims address above
PAYER ID
HealthChoice: 71064
DOC: 71065
DRS: 71065
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The HealthChoice and Department of Corrections 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, 2017, the following changes are effective for HealthChoice and DOC MS-DRG fee schedules:
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, 2018.
MS-DRG LTCH
For charges incurred on and after Oct. 1, 2017, the following changes are effective for HealthChoice and DOC MS-DRG LTCH fee schedules:
- Version 35 of the MS-DRG LTCH fee schedule has a base rate of $52,661.00. The outlier threshold is $27,382.00 and the cost-to-charge ratio is 0.248.
The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2018.
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.
HealthChoice, DOC and DRS are excited to announce call center improvements under the new TPA. The call center is staffed by 40 dedicated provider customer service representatives and 20 dedicated member customer service representatives.
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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.
For dates of service beginning Jan. 1, 2018, HealthChoice has adopted 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 launched our new Advanced Communication Engine system. ACE is available to all direct submitters as well as those who transmit claims via clearinghouses or billing services. ACE Edits will appear on claim rejection reports (277CA).
- 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 work stream, and it’s 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/billing service to stress the importance of receiving a full 277CA claim submission report to include the ACE Edits.
Effective Jan. 1, 2018, discharge status codes 02, 05, 43, and 66 will apply to the HealthChoice and the Department of Corrections transfer payment processes.
If you have questions regarding this change, contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Effective Jan. 1, 2018, HealthChoice has a new provider portal, HealthChoice Connect at http://www.healthchoiceconnect.com/.
On this self-service portal, providers can access:
- Claim status.
- Direct data entry of certification requests.
- Direct data entry of claims.
- Electronic payments.
- Electronic remittance advices in PDF.
- Eligibility.
- Member benefits.
When registering on HealthChoice Connect, you will need to use your contracted tax ID number and one contracted NPI number for authentication. Only one registration is required per TIN, as this will give you access to all contracted providers and NPI numbers under that TIN. Please note, the NPI number used must be an NPI number that we have associated with your TIN. For physicians/practitioners, this would be the individual NPI number.
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If an overpayment occurs, the 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.
Please note: The timeline for refunding 2017 and prior year overpayments will expire on April 1, 2017. You may proactively refund overpayments, otherwise HealthChoice will begin recouping all overpayments at the TIN level.
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On Jan. 1, 2018, HealthChoice and the Department of Corrections updated the CPT/HCPCS, Outpatient Facility, Ambulatory Surgery Center, American Society of Anesthesiologists, American Dental Association, and Select inpatient and outpatient fee schedules. Additionally, significant fee schedule updates will be effective April 1, 2018.
HealthChoice and DOC provider fee schedule updates on Jan. 1 of each year 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 to finalize and post its fee schedules. Please refer to the following fee schedule updates and timelines:
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Jan. 1: Comprehensive fee schedule update for ADA, ASA, and Select inpatient and outpatient fee schedules.
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Jan. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, and ASC.
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April 1: Comprehensive fee schedule update for CPT/HCPCS, OP, and ASC.
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April 1: Add, change and delete codes and other updates as necessary for Select inpatient and outpatient fee schedules.
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July 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
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Oct. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
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Oct. 1: Comprehensive fee schedule update for MS-DRG, MS-DRG LTCH, inpatient and outpatient bariatric surgery fee schedules and inpatient and outpatient tier designations.
As a reminder, 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.
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.
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 DOC 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.
Moving to a more industry standard time frame for claims processing, effective Oct. 1, 2017, HealthChoice and DOC 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 DOC 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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HealthChoice offers providers an online form to initiate the certification process. Effective Jan. 1, providers are able to enter the patient, service, provider and facility details through the portal at
www.healthchoiceconnect.com. 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, save time on the phone, and can help the process go smoothly. Please note the new phone number for certification in 2018 is toll-free 800-323-4314. The fax number will remain the same 405-416-1755.
All certifications that initiated in 2017 that apply to ongoing services in the 2018 plan year have been provided to the new certification administrator.
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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New patient is defined as a patient who has not received any professional services, i.e., E/M service or other face-to-face service from the physician/qualified health care professional or physician group practice (same physician specialty) within the previous three years.
Established patient is defined as a patient who has received professional services, i.e., E/M service or other face-to-face service from the physician/qualified health care professional or physician group practice (same physician specialty) within the past three years.
Physicians/qualified health care professionals billing new patient procedure codes that do not meet the criteria as a new patient will be denied as not an eligible service.
If you have questions, contact 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
www.healthchoiceconnect.com
HealthSCOPE Benefits
P.O. Box 99011
Lubbock, TX 79490-9011
Customer Care and Claims
Toll-free 800-323-4314
Toll-free Fax 800-496-3138
TTY 711
Toll-free TTY 800-545-8279
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
Toll-free 800-323-4314
HealthChoice HCMU
OKC Area 405-717-8879
Toll-free 800-543-6044, ext. 8879
HealthChoice Network Management
OKC Area 405-717-8790
Toll-free 844-804-2642
EGID.NetworkManagement@omes.ok.gov
ECHO Health
www.providerpayments.com
Toll-free 844-586-7463
Subrogation Administrator
McAfee & Taft 800-235-9621
DOC Network Management
https://gateway.sib.ok.gov/DOC
OKC Area 405-717-8750
Toll-free 866-573-8462
EGID.DOCNetworkManagement@omes.ok.gov
DOC Medical and Dental Claims
HealthSCOPE Benefits
P.O. Box 16532
Lubbock, TX 79490-6532
Toll-free 800-323-3710
DRS Network Management
https://gateway.sib.ok.gov/DRS
OKC Area 405-717-8921
Toll-free 888-835-6919
EGID.DRSNetworkManagement@omes.ok.gov
DRS Medical and Dental Claims
HealthSCOPE Benefits
P.O. Box 16485
Lubbock, TX 79490-6485
Toll-free 800-285-6815
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