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Providers can appeal a claim payment or denial by submitting a letter to the medical and dental claims administrator at the address designated for appeals and provider inquiries within one year of the date of the first notice of the adverse determination.
Appeals and Provider Inquiries
HealthChoice
P.O. Box 3897
Little Rock, AR 72203-3897
Claim denials requesting additional information in order to resolve a claim are not considered appeals or provider inquiries and should be sent to the claims address, listed below:
Claims Address
HealthChoice
P.O. Box 99011
Lubbock, TX 79490-9011
For additional information on the appeals process, please refer to the Provider Claim Inquiries section of the HealthChoice Provider Manual.
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The HealthChoice certification list, updated quarterly, is available through the online HealthChoice Fee Schedule. Log in to view the most recent list.
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For charges incurred on Oct. 1, 2019, and after, HealthChoice and the Department of Corrections will make comprehensive updates for MS-DRG, MS-DRG LTCH, inpatient and outpatient tier designations, and inpatient and outpatient bariatric surgery fee schedules. Additionally, updates to add, change and delete codes will be done as necessary for CPT/HCPCS, outpatient facility, ambulatory surgery center, and Select inpatient and outpatient fee schedules.
Inpatient and outpatient tier designations are updated annually on Oct. 1, based on the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file for network providers.
Please refer to the following fee schedule updates and timelines:
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Jan. 1: Comprehensive 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 update for CPT/HCPCS, OP, and ASC fee schedules.
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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 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.
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Oklahoma House Bill 2962, which amended Title 36 O.S. 2011, § 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 supervisor of the 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, call the medical claims administrator. Refer to Network Provider Contact Information.
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The CMS Local Coverage Determination guidelines for approval of intraoperative neurophysiologic monitoring claims by HealthChoice was effective Jan. 1, 2019.
View the most current version of LCD guidelines for IONM (L35003) by reviewing and accepting the CMS Licensing Agreements.
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If you receive a refund request from HealthChoice, please include a copy of the overpayment letter along with the refund check. If you have identified the overpayment and are returning funds, please include the patient name, HealthChoice member ID number, transaction ID number and date of service.
Please send all refund checks to the following address:
HealthChoice
P.O. Box 34006
Little Rock, AR 72203
Sending all refunds to the above address will expedite the process and prevent additional refund request letters from being sent.
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 applies to the HealthChoice High and High Alternative Plans. High Deductible Health Plan members must first meet the deductible before the copay applies.
If you have questions, contact network management. Refer to Network Provider Contact Information near the bottom of this newsletter.
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The medical and dental claims administrator no longer accepts verification of other insurance submitted by the provider. The member must complete the verification of other insurance process through the member portal at www.healthchoiceconnect.com or by calling customer care at toll-free 800-323-4314.
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EGID has resolved a previously communicated issue regarding supplementary data elements missing from the electronic remittance advice for 835 transmissions. These data elements assist with processing and posting recoupments.
The additional transaction information now includes the data elements, such as the original claim number, the date of service, and patient account number.
If your organization does not receive ERAs, you are not impacted by this issue and may disregard this notice.
If you have any questions, please call the medical and dental claims administrator at toll-free 800-323-4314. TTY users call 711.
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EGID has partnered with an outside vendor named VARIS, which is conducting inpatient post-payment reviews. VARIS is reviewing for DRG coding, DRG billing and DRG processing.
Medical records will be needed from your facility for this post-payment review if your claim is selected. All medical records need to be sent directly to the address indicated on the request. There could be a possible retraction of the full payment if the records are not received within 60 days.
VARIS will review for any DRG change and provide a letter with rationale for change. The facility will have 60 days to sign the acknowledgment letter and include the overpayment. If you do not agree with the DRG change, please send a letter of appeal and any additional supporting documentation to VARIS. All contract provisions apply.
VARIS will work directly with each facility regarding any questions from your facility.
For more information, please refer to the Inpatient Post-Payment Review section of the HealthChoice Provider Manual.
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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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