Winter 2021

In this issue

• CPT 87633
• Applied behavior analysis and RBTs
• HealthChoice applications and contracts
• Observation stays
• Employees Group Insurance Division announces personnel changes
• MS-DRG and MS-DRG LTCH version 38 fee schedule updates
• Fee schedule updates
• Contact information

News

CPT 87633

Effective April 1, 2021, CPT code 87633 will no longer be covered on the HealthChoice CPT fee schedule. Used for respiratory viral panels with 12-25 targets, this code will be covered on the outpatient fee schedule when billed with revenue code 450 (emergency room visit). CPT codes 87631 (3-5 targets) and 87632 (6-11 targets) will continue to be covered on HealthChoice CPT fee schedule.

Applied behavior analysis and RBTs

Effective Jan. 1, 2021, HealthChoice will begin reimbursing for ABA services performed by registered behavior technicians and contracting with RBTs who have obtained certification with the Behavior Analyst Certification Board.

For more information on HealthChoice behavioral analysis benefits and limitations, refer to the HealthChoice Provider Manual.

The HealthChoice Provider Search page will also utilize Behavior Analysis as a new specialty, which will include providers with a license of BCBA, BCaBA or RBT who are participating in
the HealthChoice Provider Network.

Please note that any services performed in a school setting (typically billed with POS 03), regardless of provider type, are excluded from reimbursement.

For questions or more information, please contact network management at
EGID.NetworkManagement@omes.ok.gov, or call 405-717-8790 or toll-free 844-804-2642. TTY users call 711.

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HealthChoice applications and contracts

HealthChoice has consolidated the provider contracts into three documents. Effective Jan. 1, 2021, you will choose one of three contracts - Practitioner, Independent Health Organization and Facility. To determine which contract is most appropriate for you, refer to Page 2.

In addition to the new contracts, HealthChoice has implemented new applications, contained within each contract document. This will substantially reduce the amount of paperwork over utilizing the Uniform Credentialing Application; however, if you have a UCA already completed, you can submit that in lieu of the contract application. The UCA will no longer be available on the HealthChoice website.

The use of a billing address will be discontinued on all documentation. The mailing address will be utilized for all payments, legal and contractual notices. All notices and documents will be sent electronically, so an email address is required on all documents.

HealthChoice has also updated the additional office location and change forms. The new forms can be used by all network practitioners, independent health organizations and facilities.

For the fastest turn around, Network Management encourages you to send your documents to the email address below. To aid in keeping the documents electronic, HealthChoice accepts electronic and e-signatures on all contracts, applications and forms.

For questions or more information, please contact network management at
EGID.NetworkManagement@omes.ok.gov or call 405-717-8790, toll-free 844-804-2642. TTY users call 711.

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Observation stays

Observation services are defined as reasonable and necessary services provided on a hospital's premises for the purpose of evaluating the condition of a patient to determine whether they should be admitted for more intensive inpatient care, discharged or transferred to another facility. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.

Observation services are by definition outpatient services.

Hospital billing for observation services should begin at the clock time documented in the patient’s medical record, which coincides with the time observation services are initiated in accordance with a physician’s order for observation services.

The time receiving observation services (and hospital billing) ends when all clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be released or admitted
as an inpatient.

Below are the HealthChoice guidelines for observation stays.

1. Observation stays of 47:59 hours or less:
   a. Certification is not required.
   b. Charges must be billed as outpatient services.
   c. Charges for a subsequent inpatient admission must be combined with charges for the observation stay and all charges must be billed as inpatient services.
2. Observation stays of 48 hours or longer:
   a. Observation services that meet or extend beyond a 48-hour period are not covered. Providers must obtain certification approval for inpatient status for any services that extend beyond the initial 48-hour period.

If you have any questions regarding a HealthChoice certification, or to request certification, please call the certification administrator toll-free at 800-323-4314, Option 2. TTY 711.

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Employees Group Insurance Division announces personnel changes

EGID is excited to congratulate Yasmine Barve and Jason Mathews-Payne on their recent promotions.

Yasmine has accepted the position of EGID administrator. A registered nurse and certified professional coder, she brings over 27 years of experience in insurance and public service to the role. Yasmine most recently served as EGID's director of Network Management, and prior to that was the director of the HealthChoice Health Care Management Unit for EGID.

Jason Mathews-Payne is stepping into the role of director of Network Management vacated by Yasmine. Jason has been with EGID for 14 years, and has been a Network Management supervisor for over half of that time. Jason also brings the well-rounded experience of having worked in Member Services and Health Care Management to the position.

Network Management is available to assist you at EGID.NetworkManagement@omes.ok.gov or by phone at 405-717-8790, toll-free 844-804-2642. You are also welcome to reach out to Jason Mathews­Payne at Jason.Mathews@omes.ok.gov or by phone at 405-693-4323.

MS-DRG and MS-DRG LTCH version 38 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 year's final IPPS file.

For charges incurred on or after Oct. 1, 2020, the following changes are effective for the HealthChoice and DOC MS-DRG fee schedules:

MS-DRG

The market basket update factor is 2.4%.

The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2021.

MS-DRG LTCH

For charges incurred on and after Oct. 1, 2020, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH fee schedules:

• Version 38 of the MS-DRG LTCH fee schedule has a base rate of $55,965.00. The outlier threshold is $27,195.00, while the cost-to-charge ratio is 0.224 and market basket update factor is 2.3%.

The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2021.

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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Fee schedule updates

Future fee schedule updates for services provided by HealthChoice network providers are scheduled for:

*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 contact network management.

The following terms are used in the fee schedule:

• BR: by report.
• BR1: 60% of billed charges for Tiers 1 and 2; 70% of billed charges for Tiers 3 and 4.
• BR2: 30% of billed charges for Tiers 1 and 2; 35% of billed charges for Tiers 3 and 4.
• BR3: 0% of billed charges for Tiers 1, 2, 3 and 4.
• Health: submit to health plan.
• I: incidental.
• IC: individual consideration.
• NC: non-covered.
• NOC: non-classified drugs.
• Per Diem: per diem rate.
• RX: submit to pharmacy administrator.
• TM: use of time.
• Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee.
• Anesthesia conversion factors (2020).
  • $59 CRNA.
  • $62 M.D./D.O.
  • Anesthesia assistant is 50% of allowable fee.

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Contact information

HealthChoice Providers

healthchoiceok.com

Medical and Dental Claims
healthchoiceconnect.com

HealthSCOPE Benefits
P.O. Box 99011
Lubbock, TX 79490-9011

Customer Care

Toll-free 800-323-4314
TTY 711

Pharmacy

CVS/caremark

Prior Authorization Request

Toll-free 800-294-5979

Prior Authorization Request – SilverScript (Part D)

Toll-free 855-344-0930

Certification

AHH
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
providerpayments.com

Toll-free 888-834-3511

Subrogation Administrator

McAfee & Taft 800-235-9621

DOC Network Management
gateway.sib.ok.gov/DOC

OKC area 405-717-8750
Toll-free 866-573-8462
EGID.DOCNetwork
Management@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
gateway.sib.ok.gov/DRS

OKC area 405-717-8921
Toll-free 888-835-6919
EGID.DRSNetwork
Management@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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