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HealthChoice encourages ambulatory surgery centers to bill facility charges on a form UB-04 or using 835i electronic claims. However, HealthChoice will accept facility charges when billed on a CMS 1500 form as outlined below.
When an ASC bills both the professional and ambulatory surgery center charges on a CMS 1500 form, it can be difficult to distinguish between the two.
To ensure that ASC claims and professional claims are paid as separate services and at the correct rates, providers should follow these guidelines when billing a CMS 1500 form:
- Ensure that the ASC claim does not include the rendering provider’s Type 1 NPI. On a CMS 1500 form, this information is often included in field 24. However, for ASC claims, you should leave field 24J blank.
- Include all facility information in box 33 and the ASC’s NPI in field 33a; this is the billing provider information.
- Add an SG modifier to the first modifier field for service codes. The SG modifier distinguishes the claim as an ASC claim (facility claim).
- Use the place of service indicator for an ASC; this is place of service 24.
For questions about ASC facility billing, contact the medical and dental claims administrator at toll-free 800-323-4314.
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For charges incurred Jan. 1, 2020, and after, HealthChoice and the Department of Corrections will make comprehensive updates for the ADA, ASA, and Select inpatient and outpatient fee schedules. Additionally, updates to add, change and delete codes will be done as necessary for CPT/HCPCS, outpatient facility and ambulatory surgery center 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.
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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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- Office managers.
- Referral and certification staff.
- Business office staff.
- Front office staff.
- Medical records staff.
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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.
To expedite, 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 prevent additional refund requests.
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.
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HealthChoice began utilizing the CMS Local Coverage Determination guidelines for urological supplies on May 1, 2019.
View the most current information regarding CMS LCD guidelines for urological supplies (L33803) by reviewing and accepting the CMS License Agreements.
If additional urological supply units are needed, certification is required through the HealthChoice Health Care Management Unit.
For more information about certification, please reference the HealthChoice Provider Manual.
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Remember that HealthChoice covers routine vaccinations, including the vaccine and its administration, for adults and children according to the to the Centers of Disease Control and Prevention guidelines under the medical or pharmacy benefits.
CDC recommended vaccinations, such as the flu shot, are covered at 100% 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 CDC's Recommended Vaccines by Age.
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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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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 888-834-3511
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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