|
When certification is not initiated and approved within the time frames described below, a 10% penalty is applied, if approved retrospectively. The member is not responsible for this penalty.
Certification is required within three business days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures. Certification is required within one day following emergency/urgent services.
Additional information about certifications is on the HealthChoice Provider site.
For questions about certification, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.
Back to top
HealthChoice is adding an advanced claim review (ACR). This program selects certain claims for additional coding review.
Reviews are performed by experts, including some specialty board certified physicians, registered nurses and certified coders. Medical records and/or itemized bills will be required for review.
If claims with billing and/or coding errors are identified, they will be processed to reflect the appropriate payment. Claims are reviewed pre-payment or post-payment.
What changes could you experience for claim editing starting Jan.1, 2023?
- Certain claims may deny for medical records if not already received from the provider or facility.
- If error(s) are identified, claims may partially or fully deny as:
a. Code billed is a component of another code (unbundling).
b. Over unit maximum.
c. Code billed not documented in medical records.
d. Billed DRG not supported in medical records.
For HealthChoice claims with dates of service prior to Jan. 1, 2023, ACR will not apply.
For questions about the HealthChoice ACR implementation, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.
Back to top
Beginning Jan. 1, 2023, HealthChoice will allow a maximum reimbursement of one unit per 12 calendar months for dental code D0350, which covers an unlimited number of photos. D0350 will not be reimbursed per tooth or per quadrant. Services billed that exceed the limitation will be applied to member responsibility.
Refer to the HealthChoice Fee Schedule(s) for coverage of codes, allowable fees and certification requirements.
For questions about eligibility and benefits, certifications or exclusions pertaining to medical or dental care, refer to the dental plan handbook or call the Customer Care team at toll-free 800-323-4314. TTY users call 711.
Back to top
Beginning Jan. 1, 2023, claims processing for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) will move to UMR.
The HealthChoice code review vendor will also change from HealthSCOPE/McKesson to UMR/Clinical Editing System (CES).
The UMR Code Review team reviews all newly implemented codes. CES applies the editing on claims received for processing.
What changes might you experience for claim editing, beginning Jan. 1, 2023?
- Claims with a code-to-code relationship present, billing of modifier 59 or equivalent X modifiers will not automatically override the claim editing. UMR will require medical records for review.
- Claims with a code-to-code relationship present between an E & M code and procedure code, billing of a modifier 25 will not automatically override the claim editing. UMR will require medical records for review.
- HealthChoice facility claims will now receive code editing.
For HealthChoice claims with dates of service before Jan. 1, 2023, HealthSCOPE/McKesson will continue to apply editing on claims.
For questions about the claim submission process, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.
Back to top
HealthChoice will be mailing new ID cards to all HealthChoice members in December for the 2023 plan year.
The new HealthChoice ID cards will now serve as the only insurance card for health, dental and pharmacy.
The new cards will also include the updated group number 76415077.
Medical, dental and RX plan sample card
 Back to top
|
