Winter 2020 Network News

Network News Masthead

Winter 2020


In This Issue


NEWS


ASC facility claims billing tips

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, call the medical and dental claims administrator at toll-free 800-323-4314. TTY users call 711.

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Fee schedule updates

On Jan. 1, 2020, 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, 2020. 

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 update for CPT/HCPCS, OP and ASC fee schedules.
  • 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 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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Flu season

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% 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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  • Referral and certification staff.
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NEWS


HealthChoice certification portal enhancements

Through the HealthChoice certification portal, you can now complete and submit a certification request form online and upload documents when requesting certification for services reviewed by the HealthChoice Health Care Management Unit.

The certification portal is separated into services reviewed by HCMU and services reviewed by the certification administrator, AHH. These changes are only applicable to services reviewed by HCMU. Please note that certification requests that are not accurately completed or are submitted to the incorrect area could be delayed or not processed.

Visit www.healthchoiceconnect.com and select Certification Portal under Providers Additional Resources. For questions or assistance navigating the portal, please call customer care at toll-free 800-323-4314. TTY users call 711.


Drug administration code

Effective Jan. 1, 2020, HealthChoice requires providers to indicate on drug administration claims the name of the drug being administered, even if reimbursement is not being requested for the drug. HealthChoice will not pay for the administration charge unless the drug is covered and medically necessary.

For questions about this change, call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.


Dental and behavioral health providers: report actual charges on claims

HealthChoice urges dental and behavioral health providers to report actual billed charges on claims and not the HealthChoice allowed charges. Billing the allowed charges can result in a misrepresentation of costs in this market. Artificially reducing your billed charges to represent contracted rates can affect statistics HealthChoice uses to determine allowed charges for services.


MS-DRG and MS-DRG LTCH version 37 fee schedule updates

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 final inpatient prospective payment system file.

For charges incurred on and after Oct. 1, 2019, the following changes are effective for the HealthChoice and DOC MS-DRG fee schedules:

MS-DRG

Tier

1

2

3

4

Outlier threshold

$124,291

 

$95,568 $80,954 $66,024

Marginal cost factor

0.32 0.35 0.41 0.50

Base rate

$11,204 $10,409 $11,755 $10,824

The market basket update factor is 3%.

The next comprehensive MS-DRG fee schedule update will be effective for charges incurred on or after Oct. 1, 2020.

MS-DRG LTCH

For charges incurred on and after Oct. 1, 2019, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH fee schedules:

  • Version 37 of the MS-DRG LTCH fee schedule has a base rate of $54,706. The outlier threshold is $26,778 while the cost-to-charge ratio is 0.233 and market basket update factor is 2.5%.

The next comprehensive MS-DRG LTCH fee schedule update will be effective for charges incurred on or after Oct. 1, 2020.

If you have any questions regarding these adjustments, please call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.

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HealthChoice certification list

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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Contact information

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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