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The annual update to the MS-DRG fee schedules for acute inpatient reimbursement for HealthChoice and Department of Corrections was done last fall. It includes updates to tier designations based on the number of beds and provider type designation as urban or rural as contained within the 2018 final IPPS file.
MS-DRG
Tier
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1
|
2
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3
|
4
|
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Outlier Threshold
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$117,120 |
$87,048 |
$63,160 |
$57,130 |
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Marginal Cost Factor
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0.33 |
0.37 |
0.51 |
0.56 |
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Base Rate
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$10,878 |
$10,106 |
$11,581 |
$10,824 |
The market basket update factor is 2.9%.
MS-DRG LTCH
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 customer care toll-free at 800-323-4314 or TTY 711.
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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 shcedules. Additionally, significant fee schedule updates are 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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The HealthChoice certification list, updated quarterly, is available through the online HealthChoice fee schedule at
https://gateway.sib.ok.gov/feeschedule/Login.aspx. Log in to view the most recent list.
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Back in the fall, the fax number for the certification administrator changed to toll-free 855-532-6780.
This 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, contact network management. Refer to Network Provider Contact Information at the end of this newsletter.
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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. EGID has phased out the old numbers.
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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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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Your patients with HealthChoice primary coverage may be able to get certain imaging, cardiology or surgical procedures covered at 100% 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 your 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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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 is selected and applies benefits accordingly.
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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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