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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.
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In 2019, HealthChoice adopted the CMS outpatient consolidated payment methodology for urban outpatient reimbursement. This applies to claims containing an HCPCS code with a status indicator of J1.
Under the CMS Hospital Outpatient Prospective Payment System (OPPS), comprehensive APC (C-APC) HCPCS codes are designated with a J1 status indicator on the OPPS Addendum B. The single payment for a C-APC is based on the primary HCPCS code with a J1 indicator and generally includes all services and items billed on the outpatient claim. There are a few carve-out items that receive separate reimbursement.
Additional rules apply to C-APC consolidated payments under CMS.
For more information, reference the current CMS OPPS files or email EGID Network Management or call 405-717-8790, toll-free 844-804-2642. TTY users call 711.
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For dates of services after Jan. 1, 2023, HealthChoice is changing the psychiatric office visit copay from a specialist copay of $50 to a primary care office visit copay of $30.
The following specialties are subject to the primary care office visit copay of $30.
- General practice.
- Internal medicine.
- Obstetrics/gynecology.
- Pediatric medicine.
- Physician assistant.
- Nurse practitioner.
- Psychiatry.
- Geriatrics.
- Preventive medicine.
- Urgent care.
- Rural health clinics.
- Federally qualified health centers.
- Military facilities.
- VA facilities.
- Indian health facilities.
All other specialties are subject to the specialist office visit copay which remains $50.
For questions about eligibility and benefits, call the Customer Care team at toll-free 800-323-4314. TTY users call 711.
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With the third-party administrator transition to UMR on Jan. 1, 2023, you will see many improvements.
Employees Group Insurance Division will continue to administer HealthChoice, determining plan benefits, administrative rules and reimbursement. UMR adds enhanced integrated provider support with flexible technology and advances in automated procedures.
You will experience user-friendly access to benefits, eligibility, claim status, remittance advice, certification requests, filing appeals, and payment options, as well as ease of submitting requested documentation with the new provider portal.
Access to the provider portals is available at HealthChoiceOK.com. For benefits, eligibility and services on or after Jan. 1, 2023, use the new portal. The first time you use it, you will need to create or use an existing One Healthcare ID, and then create a new provider account even if you have used the previous portal. For claim status and remittance advice for services prior to 2023, continue to use the HealthChoice Connect portal.
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