2024 Fall Network News

• Pre-payment audits of inpatient hospital claims 
• Pre-payment audits of claims with emergency department billing codes 
• Fee schedule additions for non-covered services in an emergency setting
• Timely filing and appeals
• Medical rehabilitation reimbursement
• Termination of inactive provider contracts
• Billing for DOC inmates
• Change of address
• Certification requests
• MS-DRG and MS-DRG LTCH Fee Schedules: Version 42 updates
• Fee schedule updates
• HealthChoice contact information

All inpatient hospital claims incurred on or after Jan. 1, 2025, which reach the outlier threshold, are subject to pre-payment audit. If the itemized bill is not attached, the claim will deny requesting the missing information. Documentation can be uploaded through the provider portal using the PCH tool.

If you have questions or issues with submitting documentation using the PCH tool, use the Contact Us option on the PCH website.

Claims questions should be directed to the Customer Care team at toll-free 800-323-4314.

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The third-party administrator for HealthChoice will begin performing more extensive audits of facility claims filed with emergency department visit billing codes. If your claim is selected for an audit, it will be denied requesting medical records to ensure the records substantiate the level of care being billed.

If the medical records do not substantiate the level of care billed, the claim will be adjusted to reflect the appropriate lower level of care.

If you disagree with the adverse determination made during the audit, you may file an appeal and submit any additional documentation through the provider portal using the claim appeal submission option.

For questions, call the Customer Care team at 800-323-4314.

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On the Oct. 1 quarterly fee schedule updates, new columns have been added to the downloadable fee schedules to reflect allowable fees for non-covered services in an emergency setting. These columns are indicated on the fee schedules with columns ending in ER. These will not be available on the Search by Code function.

For more information, email EGID Network Management or call 405-717-8790, toll-free 844-804-2642.

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All original claim submissions must be filed within 180 days from the date of service. Corrected claim submissions must be filed within 180 days from the original processed date. Secondary and tertiary claim submissions must be filed within 180 days from the previous responsible carrier’s processed date.

Each HealthChoice contract contains timely filing provisions. Claims can be filed electronically with payer ID 71064, through the provider portal (you can upload a claim with PCH or manually key a claim with iEDI), or by mail.

Any certification request denied in whole or part can be appealed within 180 days from the date of the denial. Any claim denied in whole or part can be appealed within 180 days of the date of the original claim denial, as documented on each remittance advice. If you are eligible for a second-level review, it must be filed within 90 days from the date of the first-level response.

Initiate your appeal and upload documentation through the provider portal using the claim appeal submission option. If you need assistance, contact Customer Care at toll-free 800-323-4314.

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

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Our intent is to process inpatient medical rehabilitation (revenue codes 01x8) based on the Revenue fee schedule, using a per diem methodology. View reimbursement rates by logging in to the fee schedule portal.

For questions, email EGID Network Management or call toll-free 844-804-2642. TTY users call 711.

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Oklahoma Senate Bill 442 requires all health plans to notify providers who have not filed a claim within 12 months. The health plan must terminate your contract unless you respond within 30 days indicating you wish to remain contracted.

Notices are emailed to providers from egid.networkmanagement@omes.ok.gov. We will continue this process going forward, which includes any existing contracts with HealthChoice, DRS and DOC. This notice is sent annually to the contact person we currently have on file.

If you believe your contract was terminated in error, contact EGID Network Management. You must respond timely to any termination notices to avoid removal from network participation.

For questions, email EGID Network Management or call 405-717-8790 or toll-free 844-804-2642.

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To be reimbursed for medical or dental services provided to DOC inmates, you must bill the Department of Corrections within 120 days of providing services and adhere to following the directions below.

You may file claims electronically with payer ID 71065, through the provider portal (you can upload a claim with PCH or you can manually key a claim with iEDI), or mail paper claims to DOC Claims, P.O. Box 30522, Salt Lake City, UT 84130-0522.

• Bill with group number 76415170.
• Add the prefix 365000 to the DOC inmate ID number if it is 6 digits.
• Add the prefix 36500 to the DOC inmate ID number if it is 7 digits.
• Enter the updated prefix + digit DOC inmate ID number when making a DOC inquiry using the IVR system or provider portal.

The updated DOC inmate ID number, after adding the prefix, should always be 12 digits. To verify the DOC inmate ID number, visit https://okoffender.doc.ok.gov/.

You cannot invoice or balance bill the inmate for reimbursement. Invoices received by DOC or the inmate will be disregarded. DOC claims are paid at 100% of the fee schedule allowable. You can view allowable amounts for DOC claims by logging into the DOC Fee Schedule.

For questions, call the Customer Care team at toll-free 800-323-3710. TTY users call 711.

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Previously we notified you that EGID has transitioned to the Oklahoma Healthcare Authority. With that transition, EGID has moved physical locations and will be located at the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Ste. 100, Oklahoma City, OK 73105.

The claims addresses for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS) and the appeals address for HealthChoice remain the same. The claims administrator has not changed.

Continue sending inquiries regarding provider contracts and applications, fee schedules, escalated matters as well as other provider issues to EGID Network Management or call 405-717-8790 or toll-free 844-804-2642.

EGID Network Management is available Monday through Friday, 8 a.m. to 4:30 p.m., excluding state holidays.

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HealthChoice does not accept faxed certification requests. All certification requests must be entered through the provider portal. Responses and updates to certification requests are quicker and more efficient using the portal.

Search previously submitted cases to view the status, upload any necessary records, view the original submission or initiate a preservice appeal.

To initiate a request, navigate to the provider portal log-in page and select Get certification. You can also initiate a request once logged in by selecting Providers from the menu and then select the portal.

If you have questions or need assistance with the portal, call the Customer Care team at toll-free 800-323-4314.

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