Advanced Claim Review (ACR) isa program that selects certain claims for additional coding review. 

Reviews are performed by experts, including some specialty board certified physicians, registered nurses and certified coders. Medical records and/or itemized bills will be required for review. 

If claims with billing and/or coding errors are identified, they will be processed to reflect the appropriate payment. Claims are reviewed pre-payment or post-payment. 

What you could experience with claim editing: 

1. Certain claims may deny for medical records if not already received from the provider or facility.
2. If error(s) are identified, claims may partially or fully deny as:
   a. Code billed is a component of another code (unbundling).
   b. Over unit maximum.
   c. Code billed not documented in medical records.
   d. Billed DRG not supported in medical records.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

Medical and dental claim appeals

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 this 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.

HealthChoice encourages ambulatory surgery centers to bill facility charges on a form UB-04 or through 835i electronic claims. However, HealthChoice will accept facility charges when billed on a CMS 1500 form as outlined below.

When an ASC bills both the professional and ambulatory surgery center charges on a CMS 1500 form, it can be difficult to distinguish between the two.

To ensure that ASC claims and professional claims are paid as separate services and at the correct rates, providers should follow these guidelines when billing a CMS 1500 form:  

• Ensure that the ASC claim does not include the rendering provider’s Type 1 NPI. On a CMS 1500 form, this information is often included in field 24. However, for ASC claims, you should leave field 24J blank.
• Include all facility information in box 33 and the ASC’s NPI in field 33a; this is the billing provider information.
• Add an SG modifier to the first modifier field for service codes. The SG modifier distinguishes the claim as an ASC claim (facility claim).
• Use the place of service indicator for an ASC; this is place of service 24.

For questions about ASC facility billing, contact Customer Care at toll-free 800-323-4314.

Specific bariatric surgical procedures can be covered, subject to certification and clinical criteria and guidelines. These procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP) Comprehensive Center of Excellence contracted with HealthChoice as a network facility provider. 

The benefit also includes related pre-operative and workup services. All covered procedures and related services are subject to plan provisions including member liability for copay, coinsurance and deductible amounts. The covered procedures are: 

• Sleeve.
• Bypass.
• Duodenal switch.
• Revision and conversions of a sleeve, bypass or duodenal switch procedure when medically necessary. 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.
  • Under the HealthChoice plans on or after Jan. 1, 2017.

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. These services are subject to bundled reimbursement methodology and plan provisions including member liability for copay, coinsurance and deductible amounts. 

To be eligible for the benefit, participants must be a HealthChoice member, spouse or child, age 18 or older, with no other primary coverage. 

• The participant must be covered under a HealthChoice health plan for 12 consecutive months prior to bariatric surgery regardless if the member has been eligible under other plans offered by EGID.
• The participant will be encouraged to continue health coverage with HealthChoice for 24 months post-surgery.
• 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.

The following services are not covered: 

• Band and band revisions.
• Bariatric surgical services obtained from any facility that is not a HealthChoice bariatric network provider.
• Revisions to bariatric surgical procedures originally obtained during a time when the individual was not covered by HealthChoice.
• Revisions to bariatric surgical procedures originally obtained from a facility that was not a HealthChoice bariatric network provider.
• Related workup and postoperative services billed with a diagnosis code of obesity (ICD-10 code E66).

HealthChoice is partnering with CARE to help give eligible plan participants the resources they need to live their best lives. Read more.

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 can be found on the HealthChoice Certification page. 

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711. 

PCH is the claims submission vendor for UMR, the claims processor for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS). The PCH portal allows you to submit medical records for denied claims. 

What to expect with claims denied for medical records: 

• By referencing the ineligible code, you will see the claim was denied for medical records on your HealthChoice remittance advice.
• You will receive a letter telling you why the claim was denied and what records are needed to complete the review of the claim, including details on what is needed and where and how to submit the records back to UMR.
• To submit records online, use the PCH tool. For help with the PCH tool, select the Contact Us option on the PCH website.

For questions, call the Customer Care at toll-free 800-323-4314. TTY users call 711. 

Combined payments are utilized for all providers. Under the combined payments feature, all payments for a given day are combined into a single remittance advice for a single provider. Combined payments facilitate the processing of claim payments for providers.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

Under the terms of the network provider contract, the coordination of benefits rules are subject to change. HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Following is a brief description of the rules that apply: 

• Allowable expense is a health care expense, including deductibles, coinsurance and copayments, covered at least in part by any plan covering the person. An expense not covered by any plan covering the person is not an allowable expense. Any expense that a provider is prohibited (by law or by contract) from charging a covered person is not an allowable expense.
• The benefits paid by medical and dental plans will equal no more than the allowable expense.
• The amount of any benefit reduction by the primary plan because a covered person has failed to comply with the plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and failing to use the primary plan’s preferred provider arrangements.
• HealthChoice shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
• 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. If the primary carrier paid zero on the entire claim, then HealthChoice will pay its normal benefits (unless bullet 3 applies).
• The only amount updated in the out-of-pocket max bucket is the true OOP the member has to pay, excluding charges for non-covered services, balance billing charges from non-network providers and amounts paid by third parties.
• HealthChoice requires verification of other insurance on a rolling 12-month basis.

HealthChoice allows the billed charge or allowed amount, whichever is less, of the set copay up to the out-of-pocket maximum. All provider remittance advices and 835 transactions will reflect the accurate copay amount.

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 of $50. 

When services are rendered in place of service 20 Urgent Care Facility: location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention, the copay is $30 whether the patient is being seen by a primary care physician or specialist. This applies to the HealthChoice High and High Alternative Plans. High Deductible Health Plan members must first meet their deductible before the copay applies.  

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711. 

Credit Balance is an Optumproduct that provides on-site and remote-location resources to help providers research and resolve unsolicited and solicited overpaid claims.

What is credit balance resolution?

• This program audits credit balances and overpayments found and documented on provider ledgers.
• Optum verifies the members’ claims administered by UMR and notifies the provider of refund requests.
• Optum verifies the credit balance or overpayment amount and completes the recovery.
• Credit balance and overpayment recoveries made by Optum are sent to UMR monthly for crediting in the UMR claim payment system, and payment reimbursement is sent to HealthChoice.

For questions about credit balance resolution, call Optum at 615-503-1000, option 5.

A dental predetermination is an itemization of proposed dental charges and their reimbursements before dental services are performed. It should not be confused with certification. A predetermination is not required, but is recommended when the dental treatment plan proposed by the provider is expected to exceed $200. A predetermination also shows the financial liability of the member. It should be identified as a predetermination and submitted in the same manner as a standard paper dental claim or HIPAA 837 electronic claims submission.

CPT code 21248 is for partial restorations using implants involving less than half of the arch, while 21249 is for complete restorations involving more than half of the arch. Do not report these codes for each implant. Only report one instance of the applicable code, and report the number of implants placed in the “units” column.

Certification is required.

HealthChoice has implemented a benefit for coverage of the Centers for Disease Control and Prevention (CDC)-recognized National Diabetes Prevention Programs (DPPs) and is contracting with provider organizations in Oklahoma that have achieved full CDC recognition. The CDC National DPP is a lifestyle change program that offers evidence-based, cost-effective interventions that help prevent type 2 diabetes. The program is intended to create behavioral changes to improve healthy eating, increase physical activity and manage stress. 

Participation in the program is offered as a preventive service. HealthChoice covers qualifying preventive care services at 100% of allowable fees for a qualifying code when rendered by a participating network provider. There are no copays, deductibles or coinsurance applied under this benefit. 

All HealthChoice participants who meet DPP eligibility as established by a participating DPP provider are eligible for one year in the program. Members who successfully meet the year-one performance goal will be eligible to continue participation in ongoing maintenance sessions through year two. 

To locate a network DPP, visit the HealthChoice Provider Search site and search by specialty. 

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

UMR utilizes PCH as the claims submission vendor for the direct data entry (DDE) of claims.

To register for this service, visit the PCH homepage:

1. Select My Account from the top menu bar.
2. Select Sign up from the drop-down menu.
3. Complete the New Provider Registration form and select Submit.

Types of correspondence that can be submitted.

• Single-submission claims.
• Supporting dental documentation.
• Itemized medical statements and records.

This application does not include submission for certifications.

How to check the stats of submitted documents.

Once logged into PCH, you can check the status of submitted documents in the Reports tab.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

Durable medical equipment – brace policy

HealthChoice may allow up to a maximum of two braces for the same injury or occurrence. An additional two braces may be allowed if a new or additional injury occurs. For example, if a member injures their right ACL, HealthChoice may allow up to two braces for this distinct injury. If the member later injures their right MCL, HealthChoice may allow up to two braces for this injury. If the member later reinjures their right ACL, HealthChoice may allow up to two braces for this new occurrence. Medical necessity requirements and certification requirements apply.

Unloading knee braces and other supportive devices are not covered for the treatment of osteoarthritis or degenerative joint disease unless there is an associated injury or surgical procedure.

Documentation with the date of the new injury may be required to complete the review for the additional brace(s).

Review the HealthChoice fee schedules to determine if certification is necessary. Certification can be initiated through the Provider Portal. You can also check certification status, upload any necessary records, view the original submission or initiate a preservice appeal. Additional information on certification is located in the Policies and Guidelines section on this page.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

Durable medical equipment – rental

For DME rental charges, providers are required to submit the purchase price when the HealthChoice allowed amount is $100 or more. HealthChoice will deny these claims when the purchase price is not included.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

The payer ID or EDI number is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility and benefits and submit claims.

Use the following payer IDs for HealthChoice, DOC and DRS for claims processing:

• 71064 HealthChoice.
• 71065 DOC and DRS.

Optum – UMR’s clearinghouse for claim files – works with several clearinghouses to receive claims.

HealthChoice members received new ID cards for the 2023 plan year that reflect the payer IDs listed above. The new ID cards also have these UMR-assigned group numbers:

• 76415077 HealthChoice (member IDs did not change).
• 76415170 Oklahoma DOC (member IDs include 3650 + DOC inmate ID number).
• 76415171 Oklahoma DRS (UMR issued new member IDs).

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

5018

Providers are able to receive direct deposit of claim payments processed by UMR. You can enroll online with Optum Pay or by calling 877-620-6194.

To complete your enrollment online, you will need:

• Payment method for your organization.
  • Direct deposit (ACH).
  • Virtual card payments (VCP).
• Organization name, mailing information and tax identification number (TIN).
• Contact information for your designated Optum Pay contacts.
• Banking information for the ACH option.
• Your organization's W-9 form.
• A voided check or bank letter for each account where payments will be deposited for the ACH option.

Benefits of electronic payments

• Payments arrive sooner.
• No lost payments.
• Often see less administrative costs with receiving electronic payments.
• Payments viewable through the Optum Pay web portal.
  • Free basic service or paid premium service available with more robust reporting options.
  • Remittance advices and 835 transaction data is available.

For questions, call Customer Care at toll-free 800-323-4314. TTY Users call 711.

Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient is an exclusion under the HealthChoice plan.

For questions, email EGID Network Management or call 405-717-8790 or toll-free 844-804-2642. TTY users call 711.

EGID recognizes your need for fee schedule information in order to conduct financial impact assessments. 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.  

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.

UMR is the claims processor for HealthChoice, DOC and DRS claims. The payment disbursement vendor is Optum. 

Providers 

If you are currently enrolled under UMR payer ID 39026 with OptumInsight for 835 electronic remittance advices or Optum Pay for ERAs, you do not need to register. 

If you are not currently enrolled for remittances under UMR payer ID 39026, you can enroll at any time. UMR will automatically transfer your enrollment from payer ID 39026 to HealthChoice payer ID 71064 and DOC\DRS payer ID 71065 effective Jan. 1, 2023. 

To enroll for ERAs via OptumInsight, call 866-367-9778, choose Option 1 and ask to enroll for payer IDs 71064 and 71065. 

You can also enroll for Optum Pay ERAs. With this option, you can view and download remittance information. HealthChoice encourages you to enroll or confirm you are currently enrolled by calling 877-620-6194.

Clearinghouse connections 

You can also enroll to receive ERAs through your current clearinghouse by asking to be enrolled in payer IDs 71064 and 71065. 

What happens if I do not enroll for ERAs through OptumInsight? 

If you do not enroll for 835 remittances or ERAs, you will need to view claim information on the HealthChoice provider portal or request copies of remittances from Customer Care at toll-free 800-323-4314.

If you have any questions, call Customer Care at toll-free 800-323-4314. TTY users call 711. 

The HealthChoice code review vendor is UMR/Clinical Editing System (CES). UMR is the claims processor for HealthChoice, Department of Corrections (DOC) and Department of Rehabilitation Services (DRS). 

The UMR code review team reviews all newly implemented codes. CES applies the editing on claims received for processing. 

Changes you could experience for claim editing: 

1. Claims with a code-to-code relationship present, billing of modifier 59 or equivalent X modifiers will not automatically override the claim editing. UMR will require medical records for review.
2. Claims with a code-to-code relationship present between an E&M code and a procedure code, billing of modifier 25 will not automatically override the claim editing. UMR will require medical records for review.
3. HealthChoice facility claims will now receive code editing.

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

When medically necessary, HealthChoice allows one hearing aid, V5010-V5267, per impaired ear every 48 months up to age 18. Children up to age two are limited to four additional ear molds per calendar year. Devices are not covered or reimbursable unless prescribed, filled and dispensed by a licensed audiologist. Children under age 12 will also need a prescription from a licensed medical provider (MD or DO). 

Hearing aids and examinations for fitting or prescription for members age 18 and older and batteries for hearing aids are excluded from plan coverage even if they are medically necessary. 

There is a limit of one hearing screening and three hearing tests per calendar year. Visit the HealthChoice Preventive Services webpage for more information on qualifying preventive care services. 

When medically necessary criteria are met, HealthChoice will allow surgical implantation of the following auditory devices: 

• Auditory brainstem implants for members ages 12 and older.
  
• Monaural or binaural cochlear implants for members ages 1 and older.
• Hybrid cochlear implants for members ages 1 and older.
• All other devices (semi-implantable, bone anchored, etc.) with no age limitation.

HealthChoice allows the replacement of auditory implants once every four years and considers post-implant rehabilitation services as medically necessary for both children and adults. Services consist of six to 10 sessions lasting two and a half hours each. 

Review the HealthChoice fee schedules or call Customer Care to determine if certification is necessary. Certification can be initiated through the Provider Portal. You can also check certification status, upload any necessary records, view the original submission or initiate a preservice appeal. 

For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.

HealthChoice utilizes the Centers for Medicare & Medicaid Services (CMS) local coverage determination guidelines for approval of intraoperative neurophysiologic monitoring claims.

View the most current version of LCD guidelines for IONM (L35003) by reviewing and accepting the CMS License Agreements.

Providers will receive one 1099 for each tax identification number. Even if you share a TIN with other providers, only one 1099 will be sent. This form will be addressed to the name registered with the Internal Revenue Service and mailed to the address indicated on your Form W-9.

HealthChoice covers qualified laboratory urine drug screenings once per day per patient. As a reminder, HealthChoice covers only the following laboratory urine drug screens when medically necessary screening tests are required:

• 80300 – Drug Screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures (e.g., immunoassay) capable of being read be direct optical observation, including instrument-assisted when performed (e.g., dipsticks, cups, cards, cartridges), per date of service.
• G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter.

Clinical editing applies.

HealthChoice covers the following presumptive (qualitative) and definitive (quantitative) laboratory urine drug screenings when medically necessary. Laboratory screening and confirmation services are covered under the HealthChoice medical plan, subject to deductible, coinsurance, out-of-pocket maximums, clinical editing and all policy provisions.

• Presumptive (qualitative) laboratory urine drug screenings are limited to 12 total per calendar year; certification is not required.
  • 80300 DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES.
  • G0477 DRUG TEST PRESUMP; CPBL BEING READ DC OPT OBV ONLY.
  • G0478 DRUG TEST PRESUMP; READ BY INSTRUM-AST DC OPT OBV.
  • G0479 DRUG TEST PRESUMP; INSTRUMENTED CHEMISTRY ANLYZER.
• Definitive (quantitative) laboratory urine drug screenings are limited to four total per calendar year and certification is not required.
  • G0480 DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CL.
  • G0481 DRUG TEST DEFINITV DR ID METH P DAY 8-14 DRUG CL.
  • G0482 DRUG TEST DEFINITV DR ID METH P DAY 15-21 DR.
  • G0483 DRUG TEST DEFINITV DR ID METH P DAY 22/MORE DR CL.

If you have any questions regarding this change, please contact our medical claims administrator.

For dates of service on or after Jan. 1, 2023, EGID will apply the lesser of billed charges or the HealthChoice allowable fee across all payments.

Available on the HealthChoice Providers website, all contracts have been updated to include the lesser of language.

For questions, call EGID Network Management at 405-717-8790 or toll-free 844-804-2642. TTY users call 711.

HealthChoice is contracted with SilverScript to provide Medicare Part D benefits. Providers should contact SilverScript when a member needs a medication not listed in the HealthChoice SilverScript Medicare Formulary.

You can find a description of the plans offered by HealthChoice in the member handbooks.

There may be CPT or HCPCs codes identified with an NDC status indicator on the Professional and Outpatient-ASC fee schedules. Reference the NDC and procedure code combination on the NDC fee schedule for the allowable fee. Bill with the NDC code and the corresponding CPT/HCPCS code.

The Network News newsletter is the primary information source for HealthChoice Network Providers, delivering plan reminders and updates quarterly. Each issue meets notice requirements as set out in section XII of the Network Provider Contracts.

EGID distributes electronic versions of the newsletter and other communications to network providers from  healthchoice@service.govdelivery.com. To make sure you do not miss the newsletter or other communications, add this new email address to your safe senders list. 

The network management unit is responsible for developing the content of the Network News newsletter. This newsletter is a quarterly publication specifically for network providers. The newsletter contains the latest information regarding plan benefits, contracts and fee schedules. The newsletter also serves as the primary method by which providers receive notifications mandated by the terms of the provider contracts.

To distribute the newsletter as efficiently as possible, it is distributed electronically to each network provider’s correspondence email address. Email addresses are obtained through information submitted on contract applications. Network management also updates email addresses on a regular basis as providers submit current information connected with their practice locations.

To update email information, network providers can use the appropriate change form located on the Provider Forms webpage. Completed forms can be submitted to network management by mail, fax or email.

It is imperative providers inform network management when contact information of any type is updated. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. 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.

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.

V1.13750

The network provider contract gives EGID and the network provider the ability to terminate a contract with or without cause upon a 30-day written notice. Network providers must provide a termination notice in writing, facsimile or via email to EGID.NetworkManagement@omes.ok.gov. A confirmation notice, to the provider, will be emailed or mailed to the mailing address on record. The termination will become effective on the date indicated on the confirmation. 

A provider is terminated immediately if their license is suspended or revoked or if their professional liability insurance is cancelled or not maintained in accordance with the network provider contract.

A network provider terminating with or without cause from the HealthChoice network is prevented from recontracting with HealthChoice for a period of 12 months following the effective date of termination, unless exceptional circumstances as determined by EGID Network Management require HealthChoice to execute a new contract. 

Please make a reasonable effort to inform all of your HealthChoice patients about your termination so they can make informed decisions about future provider utilization.

Members and providers have the option to nominate a medical or dental provider who is not a member of the HealthChoice Provider Network by submitting basic information on the provider search webpage.

Members and providers can also nominate facilities already participating in the HealthChoice Provider Network to be part of the HealthChoice Select program. The Select program is 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. Only facilities can participate in HealthChoice Select, not individual practitioners.  

The contracting process may take at least several weeks. The provider or facility must satisfy our business requirements and meet our contracting standards. Nomination does not guarantee the provider or facility is eligible for participation in the network or will agree to contract with us. 

Observation services are defined as reasonable and necessary services provided on a hospital's premises for the purpose of evaluating the condition of a patient to determine whether they should be admitted for more intensive inpatient care, discharged or transferred to another facility. Observation services are commonly ordered for patients who present to the emergency department and then require a significant period of treatment or monitoring to make a decision concerning their admission or discharge. 

Observation services are by definition outpatient services. 

Hospital billing for observation services should begin at the clock time documented in the patient’s medical record, which coincides with the time observation services are initiated in accordance with a physician’s order for observation services. 

The time receiving observation services (and hospital billing) ends when all clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be released or admitted as an inpatient. 

Below are the HealthChoice guidelines for observation stays. 

1.  Observation stays of 71:59 hours or less:
   • Certification is not required. 
   • Charges must be billed as outpatient services.
   • Charges for a subsequent inpatient admission must be combined with charges for the observation stay and all charges must be billed as inpatient services.
2. Observation stays of 72 hours or longer:
   
   • Observation services that meet or extend beyond a 72-hour period are not covered. Providers must obtain certification approval for inpatient status for any services that extend beyond the initial 72-hour period.
     

For questions regarding certification, call Customer Care toll-free at 800-323-4314. TTY 711. 

Under the CMS Hospital Outpatient Prospective Payment System (OPPS), CPT codes with a J1 modifier in the CMS OPPS Addendum B are assigned to a comprehensive APC (C-APC). The single payment for the C-APC includes all services and items included on the outpatient claim. There are a few carve-out items that receive separate reimbursement. The C-APC is assigned based on the primary CPT code with a J1 modifier. A complexity adjustment is made for certain combinations of primary and secondary CPT codes. 

EGID application of CMS policy. 

• EGID applies a similar bundling logic to hospitals assigned to a Tier 1 or Tier 2. Claims with at least one CPT code and a CMS J1 status indicator will be bundled into a single-unit reimbursement for the primary J1 CPT code. The following procedure/items will be bundled into the payment for the primary procedure:  
  • Secondary procedures in the CPT range 10000-69999 or 92900-93999 (with or without a J1 status indicator).
  • Units for the primary J1 procedure beyond 1.
  • Services typically bundled for hospital outpatient surgery claims. Examples include NC – non-covered services, revenue code items without a valid CPT code and CPT codes assigned a $0 fee.
  • Implants that are billed with just a revenue code are not paid separately and are bundled into the J1 procedure fee.
  • All other items, procedures or services that CMS does not specifically carve out as a pass-through for J1 reimbursement (i.e., most lab, radiology, drugs and supplies) will be bundled into the J1 procedure reimbursement.

• The following items will be paid separately according to the CMS methodology:
  
  • Diagnostic and screening mammograms.
  • Preventive services as defined in 42 CFR410.2.
  • Ambulance services.
  • Items, procedures or services with a CMS OPPS status indicator of F, G, H, L or U.
    • F is for corneal tissue acquisition cost, certain CRNA services, and Hepatitis B vaccines.
    • G is for pass-through drugs and biologicals.
    • H is for pass-through devices.
    • L is for influenza and pneumococcal pneumonia vaccines.
    • U is for brachytherapy sources.

Steps to model J1 reimbursement using EGID’s approach. 

1. Determine if your hospital is designated by EGID as a tier 1 or tier 2 hospital. If EGID has designated your hospital as a tier 3 or tier 4 hospital, the J1 bundling methodology does not apply to your hospital.
2. Determine if the claim has a unit or units billed with a CPT code with CMS J1 status indicator. If it does, go to the next step; otherwise, the claim will be reimbursed under the standard EGID hospital outpatient payment methodology.
3. Determine if the claim has multiple units of J1 procedure or procedures. If there is only one unit billed with one J1 CPT code, then the claim is a single procedure claim. The fee on the EGID OP/ASC fee schedule will be the J1 reimbursement. All other services will be packaged and not paid separately unless the item is listed in point B. If the items are separately payable, then the EGID OP/ASC fee schedule is referenced.
4. If the claim has multiple J1 units or J1 CPTs, determine the rank used for the primary assignment using the CMS OPPS  Addendum J schedule. The lowest numerically ranked CPT code is defined as the primary CPT code for the claim. If there is no complexity adjustment, the EGID OP/ASC fee schedule will be the J1 reimbursement. All other services or procedures will be bundled and not reimbursed separately even if there is a separate fee assigned on the EGID OP/ASC fee schedule unless it is a carve-out item mentioned in point B.
5. Determine if the claim should have a complexity adjustment. CMS established the procedure-oriented APCs with different levels of groups of surgeries. For example, APCs 5191-5194 are forendovascular procedures and there is an APC for each of the four levels of complexity. Certaincombinations of procedures will receive a complexity adjustment to the next highest APC withinthe same family of procedures. The combinations of CPT codes and the next highest APCassigned are included in the CMS Addendum J.
   • Use the CMS OPPS Addendum J to determine if the primary CPT, along with any of itssecondary CPTs (or a second primary unit), receives a complexity adjustment (i.e., ahigher-level APC assignment).
   • If the CPT combination is included in the CMS Complexity Adj APC Lookup, then look atthe new APC assignment (i.e., the Complexity Adjustment Assigned APC) in the nexttable – the excerpt from the CMS Addendum A with the EGID tier fees added to it. Thehigher payment is the new bundled fee for the multiple procedures on the claim. Manyclaims will not receive a complexity adjustment as it is only for a certain combination ofCPT codes.
   • The bundling rules for other procedures and services will apply as described above.

EGID tier designation.

EGID tiers were created partly to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended only to recognize a rural reimbursement methodology if the urban or rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area. 

Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1. These designations are determined by the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the facility's ZIP code, included in the U.S. Census Bureau's metropolitan core-based statistical area. On Jan. 1, the urban/rural indicators are updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals. 

For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area. 

Inpatient and outpatient tier designations are defined as: 

• Tier 1 – Network urban facilities with more than 300 beds.
• Tier 2 – All other urban and non-network facilities.
• Tier 3 – Critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
• Tier 4 – All other network rural facilities.
• Tier 6 – Outpatient rural emergency hospitals.

For more information, email EGID Network Management, or call 405-717-8790 or toll-free 844-804-2642. TTY users call 711. 

Examples of the overpayment notification and the corresponding remit advice notification and recoupment can be found here.

The HealthChoice pharmacy network includes both independent and national chain pharmacies. There is also the option of mail service. Members can fill prescriptions for up to a 90-day supply at all HealthChoice network pharmacies at the same cost as using mail service.

For details regarding HealthChoice pharmacy benefits, including lists of commonly prescribed medications, excluded medications with preferred alternatives and specialty medications, visit the HealthChoice Pharmacy Benefits Information page.

For information regarding network pharmacies and medication lists, call the pharmacy benefit manager toll-free at 877-720-9375. TTY users call 711.

Preventive services are covered services provided for overall health maintenance such as routine health/wellness exams and tests, vaccinations, well-baby care and well-child care.  

HealthChoice covers qualifying preventive care services at 100% of allowable fees for members who meet clinical criteria. When using a HealthChoice network provider, members have no out-of-pocket cost, though there may be exceptions, limitations or clinical criteria to qualify for these services at no cost. Additionally, if services received during a preventive care visit are for something other than qualifying preventive care, the member will be responsible for the out-of-pocket cost. 

In addition to Affordable Care Act specific requirements, HealthChoice follows the recommendations of the United States Preventive Services Task Force and the American Academy of Pediatrics Bright Futures for the basis of coverage and criteria. 

Providers are encouraged to review the HealthChoice Preventive Services list for any updates, code changes or the addition/deletion of previously listed codes.  

For more details on qualifying preventive care services, visit the HealthChoice Preventive Services webpage or contact Customer Care at toll-free 800-323-4314. TTY users call 711. 

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 approves the medication for coverage at the appropriate tier.

Providers who request prior authorization must follow this process:

1. The provider’s office must call the pharmacy benefit manager (PBM). Please have the member ID number, medication name and fax number ready.
2. The PBM will do one of two things:
   1. Fax a prior authorization form to the provider’s office. The provider must complete this form.
   2. May be able to take the required information verbally over the phone. The representative will ask the necessary questions and record the answers given.
3. Once their review is complete, the PBM sends notification of the review results to the member and the provider.
4. If the medication is approved for coverage, the PBM loads the approval into their system within 24 to 48 hours. Written notification of the approval is faxed to the provider and sent to the member within 24 to 48 hours. If the prior authorization is not approved, written notification is faxed to the provider and sent to the member within 24 to 48 hours, along with information for appealing the denial.

For additional information about the HealthChoice pharmacy benefits, reference the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan Handbook or visit the pharmacy benefits information page.

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. This includes hospitals, medical supply companies, specialists, laboratories, etc.

Failure to refer to network providers will result in a review pursuant to the credentialing plan.

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

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.

SELECT continues to increase the services covered under the program to include more of those with reasonably controllable cost variances, high consumer demand and market growth.

Advantages of participating in HealthChoice Select include: 

• Procedures covered at 100% of allowable fees.*
• No copays, coinsurance or deductibles to collect.*
• Approximately 170,000 HealthChoice members in or near Oklahoma.
• Potential to increase patient volume.
• Dedicated provider directory on HealthChoice website.
• Targeted marketing to HealthChoice members.

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

Colonoscopies and sigmoidoscopies are covered under the program. To encourage members to participate in SELECT for these services, HealthChoice provides a $100 incentive payment to members.

For a list of services and procedures covered under SELECT, log in and access the SELECT fee schedule at https://gateway.sib.ok.gov/feeschedule/Login.aspx. You can also search for a list of services and procedures available through SELECT at https://gateway.sib.ok.gov/providersearch/SelectProgram.aspx. 

Be aware that participating facilities are not required to provide all of the services covered under the program. Facilities can choose any combination of services and opt in or opt out at any time, according to existing contract notification provisions. 

To participate in SELECT, facilities must agree to and sign the contract amendment listed below for each location choosing to participate. Network management will provide the Attachment A with applicable services upon request.

For more information about participating in SELECT, please call network management at 405-717-8790 or toll-free 844-804-2642 or email EGID.NetworkManagement@omes.ok.gov.

Other Helpful Links:

SELECT

The medical and dental claims administrator contracts with McAfee & Taft for subrogation recovery services. Subrogation is a plan’s right to seek reimbursement for an accident or injury caused by a third party such as a motor vehicle accident or a slip and fall.

When a claim denies for subrogation, the claims administrator sends the member a notification to contact McAfee & Taft, who then sends the member a letter and questionnaire requesting details about the medical services provided. The member may also complete the questionnaire online at www.mtsubrogation.com. Upon completion, the member is provided a confirmation number for their records. 

If the member does not provide the requested information to McAfee & Taft, the claim will be reprocessed accordingly as member responsibility.

Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. 

The following is a comprehensive list of benefits for telehealth services available through network providers: 

• HealthChoice covers telehealth services that may or may not be clinical in nature, including interactive audio and video services at an originating provider site between a member and distant site provider.
• Institutional claims must include place of service (POS) 02 and indicate the GT or GQ modifiers to qualify for reimbursement.
• Professional services only require the use of POS 02. Modifiers are not required. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance.
• HealthChoice will acknowledge and pay telehealth claims according to the CPT, HCPCS and outpatient fee schedules.
• HealthChoice excludes telepharmacy networks that use pharmacists to provide services.

All plan policies and provisions apply including HealthChoice claim editing guidelines. 

All HealthChoice contracts contain timely filing provisions. It is important that you file claims within the timely filing requirements listed below. You cannot bill members for claims denied for timely filing. 

• All original claims must be filed within 180 days from the date of service.
• Corrected claims must be filed within 180 days from the original HealthChoice process date or the corrected process date of the prior carrier.
• Secondary and tertiary claims must be filed within 180 days from the process date of the prior carrier.

For additional information, email EGID Network Management or call 405-717-8790 or toll-free 844-804- 2642. TTY users call 711.

Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits.

CDC-recommended vaccinations, such as for shingles, are covered at 100% when using a network pharmacy. These can also be covered under the health benefit if provided by a recognized network health provider, such as a physician or health department.

Vaccine administration fees are also covered at 100% if the services are provided by a network provider.

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.

• Only network physicians or network providers can provide these services under the medical benefit.
• 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.
• Non-network pharmacists are not recognized and are not covered under the medical benefit.

Covered vaccinations include:

• Anthrax.
• Chikungunya.
• Dengue.
• Flu.
• Haemophilus Influenzae.
• Hepatitis A.
• Hepatitis B.
• Human Papillomavirus.
• Influenza A.
• Influenza HD.
• Japanese Encephalitis.
• Measles.
• Meningococcal.
• Mumps.
• MPox.
• Pneumococcal.
• Poliomyelitis.
• Rabies.
• Respiratory Syncytial Virus.
• Rotavirus.
• Rubella.
• Shingrix (Shingles).
• Smallpox (Vaccinia) Vaccine.
• Tetanus Booster.
• Tetanus, Diphtheria, Pertussis.
• Tick-born Encephalitis.
• Typhoid.
• Varicella.
• Yellow Fever.
• Zoster (Shingles).

This list is not all-inclusive.

A corrective lens can be covered only one time following cataract surgery. This lens should relate to the eye on which the surgery was performed. Frames are not a covered medical benefit.  

Contact lenses are covered only for the diagnosis of keratoconus, an uncommon condition of the eye surface. 

For questions, contact Customer Care toll-free at 800-323-4314.

The wig/scalp prostheses benefit is as follows: 

• 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.
• These must be obtained from a licensed cosmetologist or durable medical equipment provider.
• For pre-Medicare plans, coverage is subject to calendar year deductible and coinsurance.
• For Medicare supplement plans, coverage is not subject to calendar year deductible or coinsurance.
• The wigs and scalp prostheses benefit will be paid per the HealthChoice fee schedule.

For questions about this benefit, call the medical claims administrator toll-free at 800-323-4314. TTY users call 711.