The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. 2013 § 2 of the Workers’ Compensation Code. Add an SG modifier to the first modifier field for service codes. Medicaid is a health care insurance program, jointly funded by the state and federal government, for low-income individuals of all ages. We've designed tools that health care providers find useful. Unspecified orthodontic procedure, by report. Medication is reimbursed separately. You can obtain, Guidelines for Osteopathic Manipulation, Physical/Occupational Therapy and Chiropractic Therapy, Intraoperative Neurophysiologic Monitoring, Outpatient CMS J1 Status Indicator Fee Modeling, Prior Authorization for Medication Process, Timely Filing for Medical and Dental Claims, Vaccines and their Administration under Pharmacy Benefits, https://gateway.sib.ok.gov/feeschedule/Login.aspx, https://gateway.sib.ok.gov/providersearch/SpecialtySearch.aspx#grid, 835 electronic remittance advice crosswalk table, For medical records requests, please visit our webpage, http://omes.ok.gov/services/healthchoice/member/pharmacy-benefits-information, https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx, Select types of procedures and fee schedules, Select Mammography and Associated Services, HealthChoice Radiology and Sleep Study Facility Contract and First Amendment Select Amendment, HealthChoice Independent Diagnostic Testing Facility Amendment, HealthChoice Select Network Ambulatory Surgery Center Amendment, https://omes.ok.gov/services/healthchoice/providers/medical-records-requests, https://omes.ok.gov/services/employees-group-insurance-division/benefit-coordinator/handbooks, https://omes.ok.gov/services/healthchoice/member/pharmacy-benefits-information, https://gateway.sib.ok.gov/providerselfservice/Default.aspx, https://omes.ok.gov/services/healthchoice/providers/provider-forms, AMB SERVICE ALS NONEMERGENCY TRANSPORT LEVEL 1, AMB SERVICE ALS EMERGENCY TRANSPORT LEVEL 1, AMBULANCE SERVICE BLS NONEMERGENCY TRANSPORT, AMBULANCE SERVICE BLS EMERGENCY TRANSPORT, AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY, PARAMED INTRCPT RURL AMB NO BILL 3 PARTY PAYER. www.healthchoiceok.com, Hours 7:30 a.m. to 6 p.m., Monday through Friday, excluding state holidays. Not covered: This is the member’s responsibility. HealthChoice requires providers to indicate the name of the drug being administered on claim submissions, even if reimbursement is not being requested for the drug. Items and services provided solely to satisfy data collection and analysis needs, including any service(s) not necessary for routine care such as specialized lab tests or drugs. Under the HealthChoice plans on or after Jan. 1, 2017. Implants that are billed with just a UB-revenue code are not paid separately and arebundled into the J1 procedure fee. Each HealthChoice Network Provider is required to adhere to and cooperate with EGID’s certification and concurrent review procedures. Complications from any such procedure not originally covered by HealthChoice. HealthChoice has adopted this policy to provide a consistent method for the resolution of disputes with network facilities. In this case, you will add preceding zeroes to the section of the NDC that does not follow the 5-4-2 format. The NDC must be 11 digits (5 digits-4 digits-2 digits) in order for it to be accepted; however, there are times when the NDC on the container does not contain 11 digits. Acceptable units of measurement are GR for gram, ML for milliliter, UN for unit, and international unit F2. If there is only one unit billed with one J1 CPT code, then the claim is a single procedure claim. Oklahoma Department of Human Services 2400 N Lincoln Boulevard. Revision Date: January 2014. Certification through HCMU is required for members ages 17 and younger. Do not report these codes for each implant. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. Medical and/or mental health treatment of any kind, including hospital care, medications and medical care or medical equipment, which is excessive or where medical necessity has not been proven. A) EGID will be applying similar bundling logic to its outpatient hospital claims beginning Jan. 1,2019. Effective Jan. 1, 2018, HealthChoice adopted industry standard claim editing guidelines, a combination of CMS, CCI and McKesson claim editing criteria, which have been evaluated for implementation based on plan experience. A separate scan sheet must be completed for each claim for which you are submitting records. Find a Provider. We added the time limit for submission of a claim to Chapter 1. www.healthchoice.silverscript.com, Toll-free 888-834-3511 have the freedom to choose a behavioral health case management provider as well as providers of other medical care.” [OAC 317:30-5-596] It is a contractual requirement that providers … Commercial (All non-Part D Plans) Related workup and postoperative services billed with a diagnosis code of obesity (ICD-10 code E66). The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice approves the medication for coverage at the appropriate tier. Box 52136 TTY users call 711. Any confinement, medical care or treatment not recommended by a duly qualified practitioner. G0477 DRUG TEST PRESUMP; CPBL BEING READ DC OPT OBV ONLY. EGID provides health and dental care benefits in accordance with the provisions of Oklahoma Statutes, (74 O.S. The HealthChoice plans are a partnership between providers, members and EGID in the delivery of health and dental care services and products that helps control costs, assists in the provision of high-quality health and dental care, and enhances provider-patient relationships. In the case of a transfer, the transfer allowable fee for the transferring facility is calculated as follows: Transfer allowable fee = (MS-DRG allowable fee/geometric mean length of stay) x (length of stay + 1 day). 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. 2020. If you consistently have issues with the claims that do not process quickly, please verify the format your intermediary or clearinghouse uses to submit your claims. The payment to the receiving facility or unit is made at the rate of its respective payment system. State of Louisiana . Approximate length of time treatments will be necessary. Speech therapy for learning disabilities or birth defects. Only one per diem per day for each authorized service can be certified. The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. HealthChoice Network Management is the primary source of information and assistance for providers participating in the HealthChoice Provider Network. 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. Chapter 3: SoonerCare Chioice The OHCA Provider Billing And Procedure Manual 26 Library Reference: OKPBPM Revision Date: August 2007 Version: 3.3 INTRODUCTION SoonerCare Choice is Oklahoma’s Medicaid Managed Care program. To participate in HealthChoice Select, facilities must agree to and sign the contract amendment listed below for each location choosing to participate. 2020 UnitedHealthcare Care Provider … Medical records will be needed from your facility for this post-payment review if your claim is selected. HealthChoice excludes telepharmacy networks that use pharmacists to provide services. Revenue codes associated with colonoscopy procedures currently allowed at 60% or 70% will initially be allowed at reduced percentages of billed charges and then will be phased out. HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Discharged/transferred to a short-term general hospital for inpatient care. ACE Edits will appear on claim rejection reports (277CA). Box 99011  This site gives you the opportunity to maintain provider information, access claim and prior authorization related functions, and receive messages from the OHCA that apply specifically to you. There is no “lesser of” calculation involving the primary carrier and HealthChoice allowable amounts or of what HealthChoice would pay in the absence of other health care coverage. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. Mail claim appeals and provider inquiries to: For more information, call the claims administrator at toll-free 800-323-4314. If you have questions or want to obtain certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. SoonerCare Choice began in 1996 in 61 rural counties in Oklahoma. Resubmit a claim only if it is not already on file. The 12-month waiting period will be waived for services required for the treatment of TMD (regardless of age) but certification is required for treatment of TMD and the 12-month waiting period is waived as part of that process. Refer to Contact Information. Chapter 1: General … Oklahoma Health Homes Services Manual – OK.gov For all infusion therapy charges, certified home skilled nursing visits are not included in the HealthChoice allowed amount, but can be billed separately. The provider receives an immediate response regarding the status of the claim with real time responses indicating if the claim has been paid, denied or suspended. Delegation Provider Manual. Secondary procedures in the CPT range 10000-69999 or 92900-93999 (with or without aJ1 status indicator). You can also search for a list of services and procedures available through HealthChoice Select at https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx. Office Manual for Health Care Professionals (applies to all regions) Mid-America Office Manual Supplement (IA, IL, IN, KS, KY, MI, MN, MO, MT, ND, NE, OH, OK, SD, WI, WY) Click here to view the 2020 Provider Manual or the 2021 Provider Manual. For example, if the provider administers two .75 milliliter vials, you would report ML1.5. The bundling rules for other procedures and services will apply the same as described in above. • Medicaid manuals, notices, inserts, updates, fee schedules, forms, and other provider resources are available on the Medicaid Provider Information website. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance. Jan. 1, 2019, EGID will implement a change to their ambulance reimbursement methodology as discussed at the public hearing on Oct. 16, 2018. Notice of Non-Discrimination. Find a Provider. The Network News newsletter is the primary information source for HealthChoice Network Providers, delivering plan reminders and updates quarterly. The benefits paid by medical and dental plans will equal no more than the allowable expense. Printed newsletters are sent via the postal service to the mailing address on record for providers without internet access or those who have undeliverable email addresses. a) OHCA is the single state agency that the Oklahoma Legislature has designated through 63 Okla. Stat. Prior to that time … in state spending on Medicaid health services will draw down an additional … Billing Manual – The Oklahoma Health Care Authority. Provider Portal Enhancements – The Oklahoma Health Care Authority Wrongful act or negligence of another when an employee or dependent has released the responsible party, unless subrogation has been waived or reduced in writing in an individual case, solely at EGID’s option, and only for good cause. The terms of the HealthChoice contract require that network providers make reasonable efforts to refer their covered patients to other network providers for medically necessary services that they cannot provide or choose not to provide. The provider must complete this form. All payment information, explanation of provider payment (EPP), and ERA will be available at ECHO Health’s multipayer portal, providerpayments.com. The State of Oklahoma appropriates funding to the Oklahoma Department of Mental Health and Substance Abuse Services for the purpose of assisting this alternative school in providing therapeutic, accredited academic services. A predetermination is not required, but is recommended when the dental treatment plan proposed by the provider is expected to exceed $200. ARTICLE II. HealthChoice providers will receive the following EFT/ERA services at no cost: HealthChoice encourages providers and facilities to reach out to ECHO Health customer service at toll-free 888-834-3511 if your organization: Claims can be submitted by paper, HIPAA 837 electronic claims submission or through the provider portal at healthchoiceconnect.com. Providers are able to submit claims electronically through acceptable clearinghouses as identified by the medical and dental claims administrator using payer ID 71064. For a more detailed list of the codes that require certification, please refer to the HealthChoice Certification Code List found at https://gateway.sib.ok.gov/feeschedule/Login.aspx. Devices, appliances, prosthetics and/or supplies, over-the-counter or otherwise, that are not primarily medical in nature and/or not considered medically necessary by the plan. Fax a prior authorization form to the provider’s office. For questions, contact network management at EGID.NetworkManagement@omes.ok.gov or call 405-717-8970 or toll-free 844-804-2642. All plan policies, provisions, deductible, copay and coinsurance apply. Oklahoma Medicaid Provider Services. For example, S9131 (PT, in home, per diem) and S9123 (nursing care, in home, by RN, per diem) can be certified at the same time for corresponding visits because they are different services. Discharged/transferred to a designated cancer center or children’s hospital. Services that are typically bundled for hospital outpatient surgery claims under EGID’s April 2018 Outpatient Fee Schedule. We also added a new Chapter 3, which contains additional filing requirements, such as prior This guide has important information on topics such as how to process a claim and prior authorization. This guide explains how to work with us. Mammoplasty (including reduction, removal of implants and symmetry). TDD users call toll-free 800-545-8279. Charges for missed or cancelled appointments, mileage, penalties, finance charges, separate charges for maintenance, record keeping or case management services. Explore the Medical and Pharmacy Policies that are used as guidelines to determine coverage in benefits programs. Disclaimer: This fee schedule is not 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. No two-word spontaneous (not just echolalia) phrases by 24 months. G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. See Q6 for unit information. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. 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. Injury or sickness which is covered under an Extended Benefits provision of previous health coverage, until such time as such individual has exhausted all extended benefits available thereunder. However, providers cannot charge any more for Oklahoma Medicaid coverage than the limits established by officials. Intentionally self-inflicted injuries or illness, except when the injury (a) resulted from being the victim of an act of domestic violence or (b) resulted from a documented medical condition (including both physical and mental health conditions) that is covered under the health plan. TTY users call 711. HealthChoice Select is a program designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed. The participant must meet specific criteria, which includes, but is not limited to, severity of obesity, reliable participation in preoperative weight-loss program that is multidisciplinary, and expectation of adherence to postoperative care. Manipulative and physical therapy for palliative care (treatment for only the relief of pain), elective care (care designed to relieve recurring subjective symptoms), or prolonged care (treatment that does not move toward resolution as documented in the evaluation or re-evaluation goals). The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. Revisions to bariatric surgical procedures originally obtained during a time when the individual was not covered by HealthChoice. Colonoscopies and sigmoidoscopies are covered under the program. That said, the focal point will be on long term care, whether that be at home, in a nursing home, or in an assisted living facility. Hours:  8 a.m. - 7 p.m., M-F, 9 a.m. - 5 p.m., Saturday, Hours:  8 a.m. – 5 p.m. M, Tu, Th, F and 1 – 5 p.m., Wednesday, Option 4 For DME, medical services or emergency prior authorization. Tobacco cessation counseling outside preventive service benefit coverage. Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. If you are experiencing difficulties, please try a different Internet browser (Chrome, Firefox, Edge or Safari). Weight-loss (bariatric) surgery that involves any of the following: Sleeve, bypass or duodenal switch performed outside of a network MSBSA-QIP certified comprehensive center for excellence. This applies to the HealthChoice High and High Alternative Plans. The plan maximum is 60 speech language pathology visits each calendar year. The HealthChoice email address healthchoiceok@service.govdelivery.com should be added to the safe contact list so network management emails are not returned as undeliverable. This program was expanded statewide in April 2004 to Promoting Interoperability Program (Formerly Electronic Health Record Incentive Program) 18 : Provider Enrollment. The HealthChoice Provider Self-Service tool at https://gateway.sib.ok.gov/providerselfservice/Default.aspx is the primary search tool available for network providers to review pertinent information regarding contract demographic information, including physical and billing addresses, phone number, provider specialty, effective date and the last four digits of the providers TIN. G0480 DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CL. If your patient requires a Step Therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department toll-free at 800-294-5979. EGID has established a four tier system for short-term acute facilities: EGID has partnered with an outside vendor named VARIS, which will be conducting inpatient post-payment reviews. www.in.gov. • OHCA Health Information Technology Program Education Team 405-522-7EHR(7347) • Forms can be found at www.okhca.org in the Provider Section . The initial bariatric surgical procedure must have been performed according to one of the following: As part of the HealthChoice bariatric surgery pilot program, dates of service Jan. 1, 2013, thru Dec. 31, 2017. Please have the member ID number, medication name and fax number ready. Note: All-inclusive includes retainer, appliances, etc. These procedures do not guarantee a member’s eligibility or payable benefits, but assure the provider the medical necessity provisions have been met. If the box for the drugs contains more than one medication, use the NDC number found on the box. Comprehensive orthodontic treatment of the transitional dentition. HealthChoice covers qualified laboratory urine drug screenings once per day per patient. One wig or scalp prostheses per calendar year is covered for members who experience hair loss due to radiation or chemotherapy treatment resulting from a covered medical condition. EDI requirements for professional (837p) and institutional (837i) claims: For DME rental charges incurred Jan. 1, 2018, and after, the provider is required to submit the purchase price when the HealthChoice allowed amount is $100 or more. The fee schedule will be based on the rates published by the Centers for Medicare & Medicaid Services with a multiple applied. Oklahoma Office of Management and Enterprise Services This data is treated as confidential and is stored securely in … Certification is performed by either the HealthChoice certification administrator or by the HealthChoice Health Care Management Unit (HCMU), depending on the type of service. Provide evidence of coverage in the form of a HealthChoice ID card. If you are using a dial-up modem, we recommend you use the CD version of the Manual. These can also be covered under the health benefit if provided by a recognized network health provider, such as a physician or health department. The form is available for download at https://omes.ok.gov/services/healthchoice/providers/medical-records-requests. Whether doing research or streamlining billing, these tools can help you … For TDD call 405-949-2281, or toll-free at 866-447-0436. 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). For additional information, call network management at 405-717-8790 or toll-free 866-573-8642. Disclaimer. When these modifications occur, EGID reviews them as quickly as possible and makes any necessary updates. Meanwhile when medicaid of oklahoma provider manual Not everone is as lucky as you … Surrogate mother expenses for non-covered participants. Items, procedures or services that have a CMS OPPS Status Indicator of F, G, H, L or U. F is for corneal tissue acquisition cost, certain CRNA services, and Hepatitis Bvaccines. SoonerCare Representatives. The participant will be encouraged to continue health coverage with HealthChoice for 24 months post-surgery. Join the Bright Health Network. If records are submitted without the scan sheet, they will be returned to you. The first step in the utilization review process is to verify benefits and eligibility. The professional consultant can subsequently request additional documentation from the provider. Have credited to its outpatient hospital claims beginning Jan. 1,2019 % when using a dial-up modem, we are to! 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