|
Beginning July 1, 2018, claims runout responsibilities for HealthChoice, DOC, and DRS claims for dates of service prior to Jan. 1, 2018, will transfer from the prior claims administrator to the current administrator.
If you have questions, contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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 period 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.
Back to Top
HealthChoice coverage for breast pumps and supplies is as follows:
Manual and Electric Breast Pumps
One breast pump (manual or electric) at 100 percent of allowable fee per pregnancy for postpartum member
- Must be obtained from a contracted HealthChoice durable medical equipment provider.
- Member must have a physician’s prescription.
Breastfeeding Supplies
Certain supplies at no cost during the postpartum period, applicable to billing codes A4281, A4282, A4283, A4284, A4285, and A4286.
If you have questions about breast pumps and supplies, call the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
The Network News is the primary information source for HealthChoice Network Providers. The newsletter provides plan update information and notice requirements as set out in Section XI of the Network Provider Contracts. Currently, the Network News is mailed or emailed to each network provider on a quarterly basis, and is also available on the HealthChoice website at http://omes.ok.gov/services/healthchoice/providers/network-news.
In an attempt to obtain updated contact information for providers and facilities, HealthChoice will reach out to network providers to obtain updates to their designated contact’s email or mailing address. The update request contains a link to a downloadable form to update the designated contact information on file. Please keep in mind that the designation of a representative to receive notices requires the signature of an authorized official. The designated contact also has direct access to the fee schedule search engine if they are receiving notifications via email. Once completed, the form can be faxed to 405-717-8977 or emailed to HealthChoice Network Management. Refer to Network Provider Contact Information at the end of this newsletter.
HealthChoice is launching this initiative to ensure the delivery of plan notices and other important information directly to your designated contact. Each provider’s designated email contact will receive the Network News and other important notices. For providers with multiple locations under one TIN, the contact must forward this information to all locations or submit an email address that automatically distributes an email to all locations.
Back to Top
Effective Jan. 1, 2018, HealthChoice covers the rental or purchase of transcutaneous electrical nerve stimulator units with certification by the Health Care Management Unit. Purchase requires rental for one month to determine efficacy and medical review by HCMU.
TENS unit supplies are eligible as:
- If two TENS leads are medically necessary, a maximum of one unit of TENS supplies are allowed per month.
- If four TENS leads are medically necessary, a maximum of two units of TENS supplies are allowed per month.
Replacement of lead wires more often than every 12 months is rarely medically necessary.
A TENS supply allowance includes electrodes, conductive paste or gel, tape or other adhesive, adhesive remover, skin preparation materials, batteries, and a battery charger (if rechargeable batteries are used).
If you have questions about TENS unit or TENS unit supplies, please contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
Effective Jan. 1, 2018, HealthChoice partnered with ECHO Health, a payment disbursement service. ECHO Health is an industry leader in payment administration, and worked very closely with HealthChoice to ensure a smooth transition.
Providers receive the following EFT/ERA services currently available for HealthChoice at no cost:
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.
Back to Top
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. To call, refer to Network Provider Contact Information at the end of this newsletter.
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.
Back to Top
HealthChoice is happy to announce the Availity web portal for the direct data entry of medical and dental claims is now available. HealthChoice providers can submit claims to HealthChoice payer ID 71064, and the service is free.
The Availity web portal can be accessed at www.availity.com. A link for Availity can also be found on the HealthChoice provider portal at www.healthchoiceconnect.com under Providers Additional Resources.
If you have any questions, contact Availity.
Back to Top
DentalXChange is now live for the direct data entry of 837D dental claims. This service is free for HealthChoice, the Department of Corrections and the Department of Rehabilitation Services dentists. Follow the link to get started today. https://register.dentalxchange.com/reg/login;jsessionid=4a61e8e6bd22f5dfa6e64e9af36d?0
When registering for DentalXChange, you will be asked for your practice management system. Open the drop-down menu and select the last option, Free DDE for Payer-Partner Claims Services. After you select Payer-Partner, a list of plans that the free services apply to will open. If you are unable to locate the free services:
- Select Contact Us and complete the online Sales Form.
- Call DentalXChange sales for assistance toll-free at 800-576-6412, ext. 455.
Back to Top
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.
Back to Top
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.
Back to Top
The medical and dental claims administrator no longer accepts verification of other insurance when submitted by the provider. Verification of other insurance must be provided to the claims administrator by the member through the member portal at www.healthchoiceconnect.com or by calling toll-free 800-323-4314.
Back to Top
As indicated in the 2017 Fall Network News, beginning April 1, 2018, HealthChoice can begin recouping all overpayments at the TIN level, regardless of the date of service of the claim. This includes claims processed by the prior TPA for 2017 and earlier dates of service as well as claims processed by the new TPA for dates of service beginning Jan. 1, 2018.
All recoupments will be handled by the current TPA beginning July 1, 2018, regardless of date of service. This is due to the cutover process for the TPA handling the runout of claims for 2017 and prior dates of service.
For additional information on cutover processes and issues, watch for emails and check our website frequently.
Back to Top
|
HealthChoice is excited to announce our new website located at https://omes.ok.gov/services/healthchoice. The website was created with the intent of more intuitive and useful navigation and more relevant search results. It also has a much improved graphics and page structure. For plan related questions, continue to contact HealthChoice Network Management. Refer to Network Provider Contact Information at the end of this newsletter.
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 it 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.
Back to Top
Effective Jan. 1, 2018, discharge status codes 02, 05, 43, and 66 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.
Back to Top
Effective Jan. 1, 2018, HealthChoice has a new provider portal, HealthChoice Connect, at 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.
Back to Top
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:
-
Jan. 1: Comprehensive fee schedule update for ADA, ASA, and Select inpatient and outpatient fee schedules.
-
Jan. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, and ASC.
-
April 1: Comprehensive fee schedule update for CPT/HCPCS, OP, and ASC.
-
April 1: Add, change and delete codes and other updates as necessary for Select inpatient and outpatient fee schedules.
-
July 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
-
Oct. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
-
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.
Back to Top
For charges incurred on and after Jan. 1, 2018, DME rental requires the provider to submit the purchase price when the HealthChoice allowable is $100 or more. DME rental claims will be denied when the purchase price is not included with the claim.
If you have questions, contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
Each HealthChoice Network Provider is required to adhere to and cooperate with EGID’s certification and concurrent review procedures. These procedures do not guarantee a member’s eligibility or payable benefits, but assure the provider the medical necessity provisions have been met. The first step in the utilization review process is to verify benefits and eligibility. To obtain this information, network providers must contact the medical and dental claims administrator. The provider can also utilize the provider portal at www.healthchoiceconnect.com to obtain the information.
Back to Top
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
|
