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HealthChoice covers qualifying preventive care services at 100% of allowable amounts when rendered by a participating network provider. Qualifying coverage may be determined by age, gender or other factors. There could be certain codes not payable in all circumstances due to other policies or guidelines, including coverage limitations, exclusions and certification requirements. Certain services can be done for preventive or diagnostic reasons. When a service is performed for the purpose of preventive screening and is appropriately reported, it will be considered under the HealthChoice preventive care services benefit. Diagnostic services are considered under the HealthChoice standard plan benefits.
For a list of HealthChoice preventive services, refer to the HealthChoice website at https://omes.ok.gov/services/healthchoice/member/preventive-services.
The HealthChoice certification list, updated quarterly, is available through the online HealthChoice fee schedule at gateway.sib.ok.gov/feeschedule/Login.aspx. Log in to view the most recent list.
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Future fee schedule updates for services provided by HealthChoice network providers are scheduled for:
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ASC
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ADA
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ASA
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Bariatric
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CPT
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HCPCS
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MS-DRG
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MS-
DRG LTCH
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OP
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Select inpatient
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Select outpatient/
ASC
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Jan. 1
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A/C/D
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Comp
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Comp
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A/C/D
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A/C/D
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A/C/D
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Comp
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A/C/D
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Comp
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April 1
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Comp
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A/C/D
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A/C/D
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Comp
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Comp
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Comp
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A/C/D
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A/C/D
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July 1
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A/C/D
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A/C/D
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A/C/D
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A/C/D
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A/C/D
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Comp
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A/C/D
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A/C/D
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Oct. 1
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A/C/D
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A/C/D
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Comp
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A/C/D
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A/C/D
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Comp
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Comp
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Comp
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Comp
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A/C/D
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*Comp – Comprehensive *A/C/D – Adds, changes, deletes and other necessary updates
As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. When these modifications occur, EGID reviews them as quickly as possible and makes any necessary updates. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary.
The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban/rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area.
Inpatient and outpatient tier designations and facility urban/rural 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 or the ZIP code of its physical location included in the U.S. Census Bureau’s metropolitan core-based statistical area. On Jan. 1, the urban/rural indicator is updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals.
For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area.
Inpatient and outpatient tier designations are defined as:
- Tier 1 – network urban facilities with greater than 300 beds.
- Tier 2 – all other urban and non-network facilities.
- Tier 3 – critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
- Tier 4 – all other network rural facilities.
Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the program will fully phase in during the next quarterly update.
Fee schedule updates are reported in each quarterly issue of the Network News newsletter. If you need specific codes and allowable fees affected by these updates, please visit our website at gateway.sib.ok.gov/feeschedule/Login.aspx and view or download the latest fee schedule addendum. The fee schedule is not publicly disclosed. It is deemed confidential pursuant to 51 O.S. and should not be disseminated, distributed or copied to persons not authorized to receive the information. If you have questions or need additional information, please call EGID Network Management at 405-717-8790 or toll-free 844-804-2642.
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