Network News Spring 2022

Employees Group Insurance Division sent this bulletin at 05/26/2022 02:32 PM CDT

Spring 2022

In this issue

Codes requiring review
ABA plan limitations removed from HealthChoice
Certification and claim appeals for medical and dental services
Timely filing and appeal deadlines for medical and dental claims
Fee schedule updates
Contact information

News

Codes requiring review

On occasion, HealthChoice will identify certain claims or codes for review and will request medical records for these claims prior to issuing payment. This helps ensure that claims meet medical necessity requirements and standards of care.

For questions, call HealthChoice Customer Care at 800-323-4314. TTY users call 711.

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ABA plan limitations removed from HealthChoice

All plan limitations for applied behavioral analysis were removed effective Jan. 1, 2022. Certification is still required. Services must meet medical necessity guidelines. As a reminder, any service provided in a school or daycare setting is still excluded from the plan.

For questions regarding certification, call EGID Health Care Management Unit at 405-717-8879. For benefits, coverage questions or claim information, please call HealthChoice Customer Care at 800-323-4314. TTY users call 711.

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Certification and claim appeals for medical and dental services

Beginning Oct. 1, providers can appeal any claim that was denied in whole or in part by submitting a letter to the claims administrator at the designated address within 180 days of receipt of denial.

Additionally, if the initial appeal is upheld, network providers can request a second-level appeal if they have additional information to submit for review within 90 days from the date of the first-level appeal response. Second-level appeals are only available to network providers.

Certification is required within three business days prior to inpatient admission, transplant procedure, specific outpatient procedures, supplies or services as indicated on the HealthChoice Certification List found on the HealthChoice website. Providers are required to request certification within one business day after services for an emergency medical condition.

If a provider wishes to appeal any part of a certification denial, it must be done within 180 days of receipt of denial. This is effective July 1, 2022.

For additional information, please call EGID Network Management at 405-717-8790 or toll-free 844-804-2642. TTY users call 711.

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Timely filing and appeal deadlines for medical and dental claims

All HealthChoice contracts contain timely filing provisions.

The following updates have been made to deadlines for claims filing:

EFFECTIVE	CHANGE
Jan. 1, 2023	All original claim submissions must be filed within 180 days from the date of service.
July 1, 2022	Corrected claim submissions must be filed within 180 days from the original processed date.
July 1, 2022	Secondary and tertiary claim submissions must be filed within 180 days from the previous responsible carrier’s processed date.
July 1, 2022	Any medical or dental certification request denied in whole or in part can be appealed within 180 days from receipt of denial.
Oct. 1, 2022	Any medical or dental claim denied in whole or in part can be appealed within 180 days of receipt of denial.

For additional information, please call EGID Network Management at 405-717-8790 or toll-free 844-804-2642. 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:

Annual Fee Schedule Releases	Jan. 1	April 1	July 1	Oct. 1
Anesthesia (ASA)	Comp
ASC and ASC Implants	A/C/D	Comp	A/C/D	A/C/D
Bariatric Surgery - Inpatient	A/C/D	A/C/D	A/C/D	Comp
Bariatric Surgery - Outpatient	Comp	A/C/D	A/C/D	A/C/D
Certification Requirements	Comp	Comp	Comp	Comp
CPT	A/C/D	Comp	A/C/D	A/C/D
Dental (ADA)	Comp	A/C/D	A/C/D	A/C/D
Diabetes Prevention Program (DPP)	Comp
Endodontic	Comp	A/C/D	A/C/D	A/C/D
HCPCS	A/C/D	Comp	A/C/D	A/C/D
MS-DRG				Comp
MS-DRG LTCH				Comp
NDC	Comp	Comp	Comp	Comp
Non-CMS Certified Facility	Comp	Comp	Comp	Comp
Outpatient	Comp	Comp	Comp	Comp
Outpatient Revenue	A/C/D	A/C/D	Comp	A/C/D
Preventive Services	Comp	A/C/D	A/C/D	A/C/D
Select Inpatient (MS-DRG)	A/C/D	A/C/D	A/C/D	A/C/D
Select Outpatient/ASC	A/C/D	A/C/D	A/C/D	A/C/D

*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 that occurs, EGID reviews the modifications 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 or 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. These designations are determined by the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the facility's ZIP code, included in the U.S. Census Bureau's metropolitan core-based statistical area. On Jan. 1, the urban/rural indicators are 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 become fully phased in during the next quarterly update.

Fee schedule updates are reported in each quarterly issue of the Network News. If you need specific codes and allowable fees affected by these updates, please view or download the latest fee schedule addendum. The fee schedule has not been publicly disclosed and 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 EGID Network Management.

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Please share this newsletter with:

Office managers.
Referral staff.
Certification staff.

Business office staff.
Medical records staff.
Providers.

Contact information

Network Management
405-717-8790
Toll-free 844-804-2642
EGID.NetworkManagement@omes.ok.gov
healthchoiceok.com

Medical and Dental Claims
Toll-free 800-323-4314
TTY 711
Payer ID: 71064
healthchoiceconnect.com

New Claims, Correspondence and Medical Records
HealthChoice
P.O. Box 99011
Lubbock, TX 79490-9011

Appeals and Provider Inquiries
HealthChoice
P.O. Box 3897
Little Rock, AR 72203-3897

Health Care Management
405-717-8879
Toll-free 800-543-6044, ext. 8879
Fax 405-949-5459 and 405-949-5501

Certification Administrator
Toll-free 800-323-4314
Fax 855-532-6780
TTY 711

Pharmacy Benefit Administrator: CVS/caremark
Prior Authorization toll-free 800-294-5979
Customer Care toll-free 877-720-9375
caremark.com

SilverScript (Medicare Part D)
Prior Authorization toll-free 855-344-0930
Customer Care toll-free 866-275-5253
healthchoice.silverscript.com

ECHO Health Services
Toll-free 888-834-3511
providerpayments.com

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