2025 Winter Network News

• Medical and dental claim appeals
• DentalXChange
• DRS billing
• Certification
• Fertility preservation services
• Billing for DOC inmates
• Physical therapy bundles added to the Select program
• Fee schedule updates
• HealthChoice contact information

Upon receiving a denial for a medical or dental claim, carefully review the denial reason code on the remittance advice (RA) to determine the appropriate next steps. Depending on the denial reason, you may need to file an appeal, provide additional certification information or submit medical records via the provider portal. The HealthChoice internal appeals process grants providers the right to request a reconsideration. Appeals must be submitted within 180 days from the date of the original RA.

To submit your appeal through the provider portal, select Claim appeal submission, then follow the steps to log in and submit the records. All claim editing denials, including those with modifiers 25 and 59, must be appealed for reconsideration.

Appeals can also be submitted in writing to the address below. Your written request should clearly indicate what is being appealed and include all applicable documentation.

HealthChoice Appeals Unit
P.O. Box 30546
Salt Lake City, UT 84130-0546

If the initial denial is upheld, providers can submit a second-level appeal, provided additional information is available for review. Second-level appeals are only available to network providers. If you are eligible for a second-level appeal, it must be filed within 90 days from the date of the first-level response. Follow the directions listed on the adverse determination.

If you need assistance or have questions, contact Customer Care toll-free at 800-323-4314.

Pharmacy prior authorization and appeals

Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice will approve the medication for coverage at the appropriate tier.

For more information on requesting a prior authorization, view the pharmacy benefits section of the Policies and Guidelines page.

If a prior authorization is denied, submitting a first-level appeal may be appropriate. Providers will receive written notification via fax, and members will be notified within 24 to 48 hours. The notification will include information on how to appeal the denial.

If the first-level appeal is denied, directions to file a second-level appeal are provided within the denial letter, or the appeal can be faxed to 405-717-8925.

For information regarding network pharmacies and medication lists, call the pharmacy benefit manager toll-free at 877-720-9375.

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If you are utilizing DentalXChange for the direct data entry of 837D dental claims, upload any necessary documents for that claim in the HealthChoice provider portal using PCH, the document submission vendor. You must first create a registration for PCH. Once logged in, you can check the status of submitted documents in the Reports tab.

Uploading documents directly to DentalXChange may cause a delay in your claim processing.

If you have questions or issues registering or using the PCH tool, use the Contact Us option.

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

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You must file claims using industry-standard formats to be reimbursed for services performed on behalf of the Department of Rehabilitation Services. The claims administrator offers several different methods of claims submission:

• Electronically file claims with payer ID 71065.
• Direct data entry of medical claims is available through Optum Intelligent EDI (iEDI), available for free, to enter claims directly online, through the portal. DentalXChange is available for the direct data entry of dental claims.
• Upload claim images through the portal.
• Mail paper claims to DRS, P.O. Box 30521, Salt Lake City, UT 84130-0521.

You must use the group number 76415171 and include the members social security number in the insured’s I.D. number field on the claim form. Claims should be submitted on an appropriate claim form with all required fields completed and legible. Timely filing limits require the claim to be filed within 180 days of the date of service.

For general questions, call Customer Care at toll-free 800-285-6815. TTY users call 711.

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Certification is a review process used to determine if certain services are medically necessary and meet clinical criteria according to HealthChoice guidelines. All certification requests must be submitted through the provider portal; paper forms and faxes are no longer accepted to initiate certification.

A “C” in the certification column of each fee schedule denotes the code requires certification. You will need to review the Legends tab to distinguish the type of service for which the certification is intended.

To initiate certification:

1. Log in to the provider portal. If you are accessing the portal for the first time, you must register with a new username and password. From there, you can submit a certification request, view the status of a certification or request an appeal.
2. Select Get Certification to begin your request. You will then be guided through the information required for submission.

Pharmacy prior authorization

Items marked with “RX” in the status code column require prior authorization through the pharmacy vendor as the item is only covered under the pharmacy benefit. To obtain a prior authorization form, contact the CVS Caremark Pharmacy Prior Authorization Department at toll-free 800-294-5979.

For information regarding network pharmacies and medication lists, call the pharmacy benefit manager at toll-free at 877-720-9375.

For questions about certification, call Customer Care toll-free at 800-323-4314.

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Effective Jan. 1, 2025, recent state legislation, known as Corinne’s Law, requires that health insurance plans in Oklahoma cover certain standard fertility preservation services for individuals of reproductive age who are diagnosed with cancer and whose medically necessary treatment may cause infertility (iatrogenic infertility).

HealthChoice does not require preauthorization for coverage of standard fertility preservation services but may apply a maximum benefit and reasonable limitations and exclusions. Additionally, the benefit is subject to the same deductible, copayment and coinsurance as other plan benefits.

When provided by or under the care or supervision of a physician, fertility preservation for iatrogenic infertility includes the following procedures:

• Collection of sperm.
• Cryopreservation of sperm.
• Ovarian stimulation and retrieval of eggs.
• Oocyte cryopreservation.

The following limitations and exclusions apply:

• Not available for embryo transfer, embryo cryopreservation or fertilization.
• Not available for storage costs.
• Limited to one cycle of fertility preservation for the lifetime of a covered, eligible member.

No other changes to infertility coverage have been made. Please refer to the HealthChoice Health Plan handbook for more detailed information on plan coverage and limitations.

For questions regarding eligibility and benefits for infertility services, contact Customer Care toll-free at 800-323-4314.

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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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HealthChoice Select is available to all HealthChoice primary members Select provides specified services at no cost to the member.* These Select services must be performed on the same day with a Select provider and are bundled into one payment.

Advantages of being a Select provider include:

• Services are covered at 100% of bundled, allowable fees.*
• No coinsurance or deductible to collect.*
• One bundled payment for the services performed on the same date.
• Potential to increase patient volume as there is no out-of-pocket cost for the member to receive services.*
• Dedicated Select provider directory on the HealthChoice website.
• Targeted marketing to HealthChoice members to drive them to Select providers.
• Eligibility for the physical therapy clinic to group contract, meaning no more individual practitioner contracts.**

Physical therapy clinics not joining Select will continue to contract providers individually.

To access applicable bundles and allowables, log in to the fee schedule portal, select the SELECT OUTPATIENT ASC Excel file and filter the procedure description column by Physical Therapy. Some bundles will still require certification.

To group-contract your physical therapy clinic and join the Select program, email EGID Network Management or call 405-717-8780 or toll-free 800-752-9475.

*Members of the HDHP must meet their deductible before any benefits, other than for preventive services, are paid by the plan.

**Group contracting is only available to those physical therapy groups who are eligible and sign up to become Select providers. To be eligible for group contracting, the clinic must primarily be involved in physical therapy. Occupational therapy or speech therapy are not currently eligible for group contracting or Select.

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