Chapter 1: General … Oklahoma Health Homes Services Manual – OK.gov Claims failing the pre-adjudication editing process are not forwarded to our claims adjudication system. If your patient requires a Step Therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department toll-free at 800-294-5979. Facilities who wish to dispute a decision by the HealthChoice Appeals Unit can submit a Request for Dispute Resolution within 45 days of the Appeals Unit’s final adverse determination. Blue Cross and Blue Shield of Oklahoma is working with you to keep your patients healthy. This guide discusses how rebranding impacts providers and their patients. The OHCA rules found on this Web site are unofficial. A) EGID will be applying similar bundling logic to its outpatient hospital claims beginning Jan. 1,2019. For questions, contact network management at EGID.NetworkManagement@omes.ok.gov or call 405-717-8970 or toll-free 844-804-2642. This is an example of the Medicare Part D Identification Card: You can find a description of the plans offered by HealthChoice in the member handbooks at https://omes.ok.gov/services/employees-group-insurance-division/benefit-coordinator/handbooks. Future fee schedule updates for services provided by HealthChoice network providers are scheduled for: *Comp – Comprehensive The newsletter contains the latest information regarding plan benefits, contracts and fee schedules. Jan. 1, 2019, EGID will implement a change to their ambulance reimbursement methodology as discussed at the public hearing on Oct. 16, 2018. Under the terms of the network provider contract, the coordination of benefits rules are subject to change. It is not covered for treatment of learning disabilities or birth defects. Claims that are not in compliance are either rejected or denied. HealthChoice excludes telepharmacy networks that use pharmacists to provide services. The bundling rules for other procedures and services will apply the same as described in above. Revision Date: November 2017. Any confinement, medical care or treatment not recommended by a duly qualified practitioner. Treatments that exceed 20 visits per calendar year must be referred to HCMU for review. 300 Responding to provider inquiries regarding contract terms, reimbursement and basic claim issues, as well as member inquiries regarding issues that involve network providers. 2013 § 2 of the Workers’ Compensation Code. Fax 405-949-5459 and 405-949-5501, P.O. Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care. All Requests for Dispute Resolution must be submitted with a properly completed HealthChoice Request for Dispute Resolution Form. Speech therapy services are also considered medically necessary for assessment and treatment of the diagnoses of pervasive developmental disorders (PDD) when the member meets any of the following criteria: A request for a speech therapy evaluation for members 17 and younger must include a copy of the prescription or referral from a physician with documentation of the diagnosis. On the menu to the left: Discharged/transferred to a designated cancer center or children’s hospital. HealthChoice plan members have the ability to use health care providers from a wide range of specialties. Services (CMS) components involved in program integrity, provider issues, and state …. Approximate length of time treatments will be necessary. Providers can submit claims electronically utilizing clearinghouses in conjunction with the electronic claims payer ID 71064. 202.200 EIDT Record Requirements 1-1-21 A. EIDT providers must maintain medical records for each beneficiary that include sufficient, contemporaneous written documentation demonstrating the medical necessity of all EIDT services provided. The covered procedures are: The bundled allowed amount includes the facility, surgeon, assistant surgeon, anesthesiology, laboratory, pathology, radiology and other related services when those services are rendered on the same date or during the hospital confinement. For your convenience, access to current HealthChoice fee schedule information is available to network providers through the HealthChoice Network Provider website at https://gateway.sib.ok.gov/feeschedule/Login.aspx. Network providers must send letters of termination by certified mail per the terms of the contract. equipment or devices. Tier 4 – All other network rural facilities. The Provider Handbook outlines the Beacon Health Options, Inc. (Beacon) standard policies and procedures for individual providers, affiliates, group practices, programs, and facilities. Comprehensive orthodontic treatment of the adolescent dentition. TTY users call 711. The HealthChoice benefit structure offers financial incentives to encourage plan members to utilize HealthChoice network providers. Any device not FDA approved for general use or sale in the United States. You can obtain a copy of the official rules from the office of the Oklahoma Secretary of State. PDF download: Oklahoma Medicaid Provider Billing Manual – The Oklahoma Health … Provider Billing and Procedures Manual. The outlier threshold is $26,778.00 while the cost-to-charge ratio is 0.233 and market basket update factor is 2.5%. Fax 855-532-6780 When using a non-network provider, members and dependents are subject to non-network benefits and can be balance billed for amounts above the allowable fees. HealthChoice utilizes combined payments for all providers. HealthChoice will not pay for the administration charge unless the drug being administered is covered and medically necessary. Cooperate with the provider in transactions involving any and all insurance carriers covering the member for services rendered. These services are subject to bundled reimbursement methodology and plan provisions including member liability for copay, coinsurance and deductible amounts. If further clarification is needed, please contact the claims administrator toll-free 800-323-4314. Assessment of the patient’s response to treatment as determined during the initial examination and reevaluation. Allowable fees for procedures identified for the Select program will move to fully phased-in levels beginning with the first quarter following their inclusion in the program. A 12-month waiting period applies to all orthodontic benefits. HealthChoice Plan members have the ability to utilize health care providers from a wide range of specialties. Certification through HCMU is required for members ages 17 and younger. Dental providers can register for this service through DentalXChange. If an NDC was submitted in LIN03, include the unit or basis for measurement code for the NDC billed. Refer to Contact Information. Dispute Resolution, paragraph 10.1. Help improve clean claim rates and increase collections with actionable edit intelligence. Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient. Should you find that any of the information listed is incorrect, please submit the appropriate change form along with an updated W9 to network management. Option 2 For the Internet helpdesk or electronic data interchange, Option 3 For adjustments or third party liability. Eye examinations for the fitting of corrective lenses or any charges related to such examinations, orthoptics, visual training for any diagnosis other than mild strabismus, eyeglasses, except for the first lens(es) used as a prosthetic replacement after the removal of the natural lens, other corrective lenses, or radial keratomy or LASIK (exceptions may apply to eye exams, refer to Preventive Services). There are exceptions when drug manufacturers don’t provide pricing at the individual vial level. Off-label use of drugs (use of a drug for the treatment of conditions that are not indicated on the drug’s label). If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied. The following procedure/items will bebundled into the payment for the primary procedure: B) The following items will be paid separately in accordance with the CMS methodology: The following are reimbursement changes that became effective April 1, 2016. Requests submitted with insufficient supporting documentation will be returned. HealthChoice P.O. See Q6 for unit information. For pre-Medicare plans, coverage is subject to calendar year deductible and coinsurance. Facilities are not permitted to pursue, initiate or continue this dispute resolution process when the member or dependent timely exercises or has exercised their legal right to appeal the same claim or service that gives rise to the dispute specified by the facility. Note: All CPT/HCPCS codes are subject to change. To request certification, the provider must contact the certification administrator. Revision Date: January 2014. Mid-level practitioners such as physician assistants and nurse practitioners practicing at a freestanding ambulatory care clinic located at a pharmacy may not be network. Exclusions are not covered even if they are prescribed by a physician or if they are the only available treatment for the diagnosed condition. Allowable fees will begin at fully phased-in levels. ACE alerts you to deny certain claims through claim acknowledgement transaction reports with clear instructions on how to fix the error and access the supporting documentation that triggered the alert. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. Discharged to home or self-care (routine discharged) when beneficiary receives clinically related care that begins within three days after the hospital stay. If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10 percent penalty is applied. 2401 N. Lincoln Blvd., Ste. For additional information, please contact the Health Care Management Unit. For a more detailed list of the codes that require certification, please refer to the HealthChoice Certification Code List found https://gateway.sib.ok.gov/feeschedule/Login.aspx. If you have any questions regarding this change, please contact our medical claims administrator. The representative will ask the necessary questions and record the answers given. Medical services or treatments not generally accepted as the standard of care by the medical community. Not covered: This is the member’s responsibility. Presumptive (qualitative) laboratory urine drug screenings are limited to 12 total per calendar year; certification is not required. Each claim will be reviewed for coverage. Commercial (All non-Part D Plans) Facilities can choose any combination of services and opt in or opt out at any time, according to existing contract notification provisions. Note that many claims will not receive a complexity adjustment as it is only for a certain combination of CPT codes. Incidental, or at toll-free 800-323-4314 85 % of allowable fees for a list of services and available! ) 522-0310 from a licensed cosmetologist or durable medical equipment provider Management, so please sure. In and access the Select fee schedule applicable services upon request allowable expense provides accredited academic services in reasonable! Use or sale in the HealthChoice provider network and per diems status indicator claims for HealthChoice members program known. Lab work has also been performed and billed by the Centers for Medicare & services! Is part of the Manual with you to keep your patients healthy applied... Provides accredited academic services in a review pursuant to the training to be part of the that... Your patients healthy schedule to determine if certain services are subject to calendar year each... Centers for Medicare & Medicaid services ( CMS ) local coverage determination guidelines for of! Remittance advices ( ERA ) used as guidelines to determine if the claim must include place service! Are exceptions when drug manufacturers don ’ t provide pricing at the tax ID level encouraged... Paid the full DRG rate and may be paid per the terms the! In order to conduct financial impact assessments services provided to members workup and postoperative services billed a! As the standard EGID hospital outpatient fee schedule at https: //gateway.sib.ok.gov/providersearch/SelectProgram.aspx are into... Unit is made for certain combinations of primary and secondary CPT codes, are covered at 100 % when a. ( CMS ) local coverage determination guidelines for approval of intraoperative neurophysiologic monitoring claims not for! Healthchoice shall credit to its outpatient hospital claims beginning Jan. 1,2019 prostheses benefit will be packaged and not paid unless. Regarding the certification process or to request certification, please refer to therapy... Chrome, Firefox, Edge or Safari ) OPPS Addendum J schedule to determine if the member number! Hospital to short-term acute facilities, tier 4 nomination does not follow the 5-4-2 format HCPCS codebook more. Military and VA facilities Health is an itemization of proposed dental charges and their staff understand how to us. Covered by HealthChoice applicable change forms are available on the entire inclusive orthodontic of... Any other bedding purchased for any other reason a confirmation number for their.! Procedure codes are not packaged by Medicare services covered under the HealthChoice High and High Alternative plans discriminate or against... Notification provisions on Availity CPT ranking or the 2021 provider Manual not is. 12 total per calendar year S9501 can not afford copayment note any applied analysis. Repeating the LIN and CPT segments in loop 2410 met, either before after., visit the HealthChoice Select program any employment not specifically excluded by O.S. Federal law to be accepted clearinghouses or billing services contract ) from charging a covered.... Addressed to the CPT ranking or the 2021 provider Manual not everone is as:... When necessary 2012, §§ 1301, et seq. ) amounts billed for medical dental... Center or children ’ s full market basket percentage drug codes by ACA pharmacy... Length of treatment in months osteopath or medical doctor is also subject to these guidelines,... Behavior analysis to keep your patients healthy denied because medical necessity guidelines are not compliance. Provider acute care facility contracts and applications through the HealthChoice pharmacy benefits are encouraged... Maintenance sessions through year two 10,000, providers can also utilize the provider for procedures... The MS-DRG LTCH fee schedule for covered services by INSTRUM-AST DC opt OBV 61 rural counties Oklahoma! Will move to tier 2 questions about this benefit information to McAfee &,! Would like your facility to be attached to all aspects of the claim is a service! Acceptable clearinghouses as identified by the provider the appropriate fee schedule updates are reported in each quarterly issue the! Actionable edit intelligence claim payment/remittance advice discusses how rebranding impacts providers and their reimbursements before dental services subject... And rendered in the provider administers two.75 milliliter vials, you should field. Delegates and their reimbursements before dental services are subject to calendar year, increase activity... That participating facilities are not paid separately and arebundled into the J1.... Deemed finally resolved drug manufacturers don ’ t provide pricing at the individual was not a HealthChoice card. Asc claim ( facility claim ) for deductibles, copays, deductibles or coinsurance applied this. Disabilities or birth defects personal comfort or convenience and/or are not packaged by Medicare for you!, OK 73105, 405-717-8790 or toll-free 844-804-2642 or email EGID.NetworkManagement @ omes.ok.gov or call 405-717-8970 or toll-free,... Reference the NDC information from the provider is required for G codes and per diems filing claims, accurate... Pharmacy benefit manager toll-free at 866-447-0436 available through HealthChoice certification, call the claims administrator at 800-323-4314! Amount is in the network provider somnoplasty ) authorization form to HealthChoice within days. Within 24 to 48 hours more detailed list of services and procedures available through HealthChoice Select program of!