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 or rural as contained within the current year’s final IPPS file.
For charges incurred on and after Oct. 1, 2018, the following changes are effective for HealthChoice and DOC MS-DRG fee schedules:
MS-DRG
Tier
|
1
|
2
|
3
|
4
|
Outlier Threshold
|
$117,120.00 |
$87,048.00 |
$63,160.00 |
$57,130.00 |
Marginal Cost Factor
|
0.33 |
0.37 |
0.51 |
0.56 |
Base Rate
|
$10,878.00 |
$10,106.00 |
$11,581.00 |
$10,824.00 |
The market basket update factor is 2.9 percent.
The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2019.
MS-DRG LTCH
For charges incurred on and after Oct. 1, 2018, the following changes are effective for HealthChoice and DOC MS-DRG LTCH fee schedules:
Version 36 of the MS-DRG LTCH fee schedule has a base rate of $53,372. The outlier threshold is $27,124 and the cost-to-charge ratio is 0.24.
The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2019. If you have any questions regarding these adjustments, please contact the medical and dental claims administrator toll-free at 800-323-4314 or TTY 711.
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The updated HealthChoice certification list effective Nov. 1, 2018, is now available through the online HealthChoice fee schedule at https://gateway.sib.ok.gov/feeschedule/Login.aspx.
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EGID heard your concerns regarding transmitting faxed information to our Health Care Management Unit. We involved not only the local and long-distance carrier but also the hardware manufacturer and our internal IT team to find a solution. This collaboration led EGID to procure new fax lines to be more compatible with the fax protocols in use today. Over the next several months, we will phase out the old numbers. All HCMU fax lines during this period will continue to be active, but we encourage you to make the switch now. Below are the new HCMU fax numbers.
Old fax numbers: 405-717-8935, 405-717-8947 New fax numbers: 405-949-5459, 405-949-5501
Please share this information with your certification staff and other stakeholders within your organization who need to know.
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When the provider who renders the service is different from the billing provider, the rendering provider information, including the individual provider’s NPI number, must be included on the claim. The rendering provider’s name and individual NPI number will help ensure that the claims administrator selects the correct network or non-network provider and applies benefits accordingly.
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If you do not already receive electronic remittance advices from your clearinghouse, you must register for HealthChoice Connect at www.healthchoiceconnect.com to receive them from HealthChoice.
If you do not receive ERAs, you will need to download your zero pay ERAs from HealthChoice Connect or from ECHO Health. Please check these resources before resubmitting claims rather than assuming they have not yet processed or are not on file.
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. 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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The HealthChoice medical and dental claims administrator is contracted with McAfee & Taft for subrogation recovery services. Subrogation is an insurance company’s right to seek reimbursement on a claim for an accident or injury caused by a third party, such as a motor vehicle accident or slip and fall.
When a claim denies for subrogation, HealthChoice sends the member a notification to contact McAfee & Taft, who also sends the member a letter and questionnaire requesting details about the medical services provided. Members may also complete a questionnaire online at www.mtsubrogation.com. Upon completion, a confirmation number is provided for their records.
If the member does not provide the requested information to McAfee & Taft, the claim will be reprocessed accordingly as member responsibility.
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Remember that HealthChoice covers routine vaccinations, including the vaccine and its administration, for adults and children according to the Centers for Disease Control and Prevention guidelines under the medical or pharmacy benefits.
CDC-recommended vaccinations, such as the flu shot, are covered at 100 percent under the medical benefit when provided by a recognized network health provider, such as a physician or health department, and under the pharmacy benefit when using a network pharmacy. For recommended vaccines and immunization schedules, visit https://www.cdc.gov/vaccines/vpd/vaccines-age.html.
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On Jan. 1, 2019, 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, 2019.
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 (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.
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Your patients with HealthChoice primary coverage may be able to get certain imaging, cardiology or surgical procedures covered at 100 percent if they utilize a HealthChoice Select provider.
HealthChoice Select is a program designed to reduce the costs of certain services by contracting with select medical facilities to provide these services with no out-of-pocket costs to members.
Members on the HealthChoice High Deductible Plan must meet their deductible before any benefits, other than preventive services, are paid by the plan.
Customer care is available to help guide referring providers and members through the HealthChoice Select process and ensure members have a positive, beneficial experience. To verify if the service is covered under HealthChoice Select and identify a participating provider, call toll-free 800-323-4314 and choose the appropriate prompt below:
- Providers select option 2, then option 3 for Select issues.
- Members select option 3, then option 5 for Select issues.
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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 TTY 711
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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- Office managers.
- Referral and certification staff.
- Business office staff.
- Front office staff.
- Medical records staff.
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