|
With the new TPA, providers might have noticed longer turnaround times as HealthChoice has moved more towards industry standard claim editing. Claims are still being processed within contractual provisions. Below are some helpful tips when it comes to the HealthChoice TPA:
- Review your 277CA transactions reports for rejected claims. Reminder: HealthChoice has adopted more industry standard claim editing guidelines, implemented with our Advanced Communication Engine System. Read all about ACE edits at omes.ok.gov/articles/advanced-communication-engine-announcement.
-
HealthChoice offers two ways to review remittance advices. You can view finalized claims the same day at www.providerpayments.com; or you can view your RA on the provider portal at www.healthchoiceconnect.com (availability of RAs can take up to five days after claims are finalized).
- HealthChoice has partnered with ECHO Health, a payment disbursement service. Sign up to receive electronic funds transfers and payment issuance email notifications at www.providerpayments.com.
- If you receive a denial on a claim for previously certified services, call the medical and dental claims administrator at the toll-free number listed below to have your claim reprocessed accordingly.
Having issues? The TPA has 40 dedicated provider customer service representatives available at toll-free 800-323-4314. In addition to assisting with issues, the TPA is your point of contact for eligibility and claim status.
Did you know that each contracted provider has a dedicated HealthChoice network management representative? Network management representatives not only contract providers under the HealthChoice plan, but they are a second point of contact for provider issues. If you are not able to get resolution through the TPA, please reach out to your dedicated network management representative at 405-717-8790 or toll-free 844-804-2642. Before your network management representative can offer assistance, you must have the name of the customer service representative and a call reference number from the TPA regarding your issue.
Back to Top
HB 2962, which amended Title 36 O.S. 2011, Section 6060.20, mandates coverage for applied behavior analysis. HealthChoice covers these services when performed by board-certified behavioral analysts (BCBA), board-certified assistant behavioral analysts (BCaBA) or doctoral-level psychologists.
Please note that services billed by a registered behavioral technician, or any applied behavioral analysis services performed in a school setting, regardless of provider type, are not eligible for reimbursement.
The maximum benefit for applied behavior analysis is 25 hours per week and no more than $25,000 per calendar year. A current treatment plan from the BCBA or BCaBA, which includes a script from the treating physician, is required upon receipt of the first claim each rolling year.
All plan policies, provisions, deductibles, copays and coinsurance apply.
For additional information on coverage of autism spectrum disorders, contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
HealthChoice and the Department of Corrections have updated the following fee schedules for added, changed and/or deleted codes for charges incurred Oct. 1, 2018, and after: CPT/HCPCS, outpatient facility, ambulatory surgery center, and Select inpatient and outpatient. A comprehensive fee schedule update was done for MS-DRG, MS-DRG LTCH, inpatient and outpatient bariatric surgery for charges incurred Oct. 1, 2018, and after.
Inpatient and outpatient tier designations are updated annually on Oct. 1, based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers.
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 (may be updated) 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
The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban/rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s Metropolitan Core Based Statistical Area.
For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s Metropolitan Core Based Statistical Area.
If you have questions about this process, please contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
The HealthChoice website at www.healthchoiceok.com has a new look. The website was created with the intent of being more intuitive, with more useful navigation and relevant search results.
In order to locate provider-specific information, select Providers under the Resources tab and choose Provider Home. You will see categories pertaining to the provider manual, certification, claim filing procedures, fee schedules, medical records requests, HealthChoice Select, contact information, forms, contracts and applications and more.
To obtain the most current contracting information, you can utilize the HealthChoice Provider Self-Service site at https://gateway.sib.ok.gov/providerselfservice/default.aspx. To navigate from the HealthChoice Providers webpage, select Provider Self-Service on the left side of the screen.
HealthChoice Connect and ClaimLink are online services where providers can check the status of medical and dental claims. ClaimLink is available through Dec. 31, 2018, for documentation. Remittance advices are available for claims with dates of service prior to Jan. 1, 2018, and processed through June 29, 2018. For claims with DOS in 2018 and 2017 and prior but processed after June 29, 2018, please visit the provider portal at www.healthchoiceconnect.com.
If you have bookmarked pages on the former site, we recommend updating those links to the new site. The redirection from the former site to the new site is temporary and can be discontinued at any time.
For any questions related to website navigation and content, please contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
DentalXChange offers direct data entry of 837D dental claims as a free service for dentists with HealthChoice, the Department of Corrections and the Department of Rehabilitation Services.
Follow the link to get started today.
https://register.dentalxchange.com/reg/login;jsessionid=4a61e8
e6bd22f5dfa6e64e9af36d?0
When registering, 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
The Availity web portal for the direct data entry of medical and dental claims is available as a free service to you. Submit claims to HealthChoice payer ID 71064.
Access the Availity web portal at www.availity.com. A link for Availity is also on the HealthChoice provider portal at www.healthchoiceconnect.com under Providers Additional Resources.
If you have any questions, contact Availity. Visit the Contact Us page on their website.
Back to Top |
Some providers are submitting paper Medicare supplement claims in addition to electronic crossover claims.
Resubmit a claim only if it is not already on file. When the same claim is submitted multiple times, each additional claim will deny as a duplicate and further delay the adjudication process.
Most electronic Medicare crossover claims will process within seven days. You are urged to utilize HealthChoice Connect at http://www.healthchoiceconnect.com to access claim status and verify the electronic claim has been received. The claim should be available on HealthChoice Connect the day after submission. You can also verify claim status by calling the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
A review of the HealthChoice certification requirements list was recently conducted. During this review, the certification requirements for orthodontia, MRIs and MRAs were removed, along with some additional changes, effective Aug. 1, 2018. For a full list of certification requirements, please review the certification spreadsheet on the HealthChoice Provider Fee Schedule page.
If you have questions about the certification requirements list, please contact the medical and dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
While a procedure code may be listed on the fee schedule, all codes are subject to plan policies and provisions, including clinical editing and medical necessity guidelines. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
Venipuncture (36415) is not covered separately when lab work has also been performed and billed by the provider. For lab tests requiring routine venipuncture and subsequently sent to an outside lab, the physician office can bill either the venipuncture service or the handling charge, but not both. These services may be denied as incidental, or included in a primary service when billed in conjunction with another service.
If further clarification is needed, please contact the medical claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
Effective immediately, the fax number for the certification administrator has changed to toll-free 855-532-6780. The new fax number is only for the certification administrator and not for the HealthChoice Health Care Management Unit.
To determine which services are certified through the certification administrator, please visit our website at omes.ok.gov/services/healthchoice/providers/provider-manual and refer to Certification.
To save time and help the certification process go smoothly, providers are encouraged to initiate certification with the certification administrator by completing the online form at www.healthchoiceconnect.com.
If you have questions about this process, please contact the medical and dental claims administrator. Refer to Network Provider Contact Information at the end of this newsletter.
Back to Top
For all charges incurred Oct.1, 2018, and after, the specialty medications listed below will only be available under pharmacy benefits for all members covered under the non-Medicare HealthChoice plans. They are currently covered under both medical and pharmacy benefits.
These medications will be subject to the restrictions and limitations outlined in the plan documents for specialty medications under the pharmacy benefit.
- Ocrevus
- Stelara
- Hizentra
- HyQvia
- HP Acthar
- Fasenra
- Benlysta
Applicable HealthChoice fee schedules will be updated during the October fee schedule update so that all applicable HCPCS and CPT codes assigned to these medications will show as Rx only.
If you have any questions, call the pharmacy benefit manager toll-free at 877-720-9375.
Back to Top
HealthChoice is offering a new and unique benefit for all HealthChoice members. The focus of the program is to strengthen the relationship between a member and their physician. If there is no provider associated with a member, care management encourages the member to find the right primary care provider and assists the member in scheduling and keeping those appointments. The philosophy is that if that relationship is strong, the member will have better health outcomes.
To assist members and providers, care management provides support to members and to providers who request the services on behalf of their patients. Through a complex data platform, care management identifies members with chronic conditions, gaps in care, ER visits, as well as those who have been pre-authorized for a procedure or inpatient stay. Care management is there to support the member with education, advice, social resources or any other necessary information needed to assist.
For the provider, care management adds additional support to their office. They spend as much time as necessary educating the member or walking through situations with them. They can assist members with how to use new DME products or simply offer a variety of healthy recipes or exercising tips. If requested, care management relays the information regarding the member to the provider to ensure that the entire team knows what is going on with the member’s health. Care management works with the member on how to manage their chronic conditions. Because they make regular contact with the member, care management can help stop a condition from deteriorating.
Care management consists of a multidisciplinary team of physicians, RNs, pharmacists and care coordinators trained in a multitude of service areas. We can proudly say that care management can change a life for the better daily. Sometimes the impact is small and incremental, but sometimes it is monumental. Whatever it takes, care management is focused on their goal for members to obtain better health.
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
Back to Top |
