This lens should relate to the eye on which the surgery was performed. The following information is required on the referral form: The following information may be requested by the professional consultant to support medical necessity: 2401 N. Lincoln Blvd., Ste. Under the combined payments feature, all payments for a given day are combined into a single remittance advice for a single provider. If an NDC was submitted in LIN03, include the administered NDC quantity. Acceptable claim forms are: Regardless of the claim form utilized, claims are processed according to the appropriate fee schedule. Please do not send medical records unless instructed to do so. The representative will ask the necessary questions and record the answers given. If you have questions or want to obtain certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. Reference the IHCP Provider Manual Chapter 6 … HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Definitive (quantitative) laboratory urine drug screenings are limited to four total per calendar year and certification is not required. Certification is required through the HealthChoice Health Care Management Unit for members aged 19 and older. Ensure that the ASC claim does not include the rendering provider’s Type 1 NPI. At Blue Cross and Blue Shield of Oklahoma (BCBSOK), we are committed to providing support to physician practices. 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. Mar 9, 2015 … OHCA Provider Billing And Procedure Manual. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. The ADvantage Administration Unit oversees the day-to-day operation of the ADvantage waiver program. Under the Medicaid Home and Community-Based Waiver ADvantage Program, the Oklahoma Department of Human Services, Division of Aging Services, offers services to eligible adults as an alternative to care in a nursing facility. AHCCCS IHS/Tribal Provider Billing Manual. Inpatient and outpatient tier designations are defined as: Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the program will become fully phased in during the next quarterly update. Interceptive orthodontic treatment of the transitional dentition. Providers can appeal a claim payment or denial by submitting a letter to the medical and dental claims administrator at the designated address within one year of the date on the first notice of the adverse determination. For additional information or with questions regarding implementation of OK AuthentiCare, contact Provider Questions. For TDD call 405-949-2281, or toll-free at 866-447-0436. All plan policies, provisions, deductible, copay and coinsurance apply. The form is available for download at https://omes.ok.gov/services/healthchoice/providers/medical-records-requests. Network management also updates email addresses on a regular basis as providers submit current information connected with their practice locations. This guide explains how to work with us. In this case, you will add preceding zeroes to the section of the NDC that does not follow the 5-4-2 format. 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. Off-label use of drugs (use of a drug for the treatment of conditions that are not indicated on the drug’s label). 300  All covered procedures and related services are subject to plan provisions including member liability for copay, coinsurance and deductible amounts. If you have questions, call the medical claims administrator at 800-323-4314. When the same claim is submitted multiple times, each additional claim can deny as a duplicate and further delay the adjudication process. HealthChoice requires verification of other insurance on a rolling 12-month basis. Visits limited to 60 total per calendar year (some exceptions apply). All other services will be packaged and not paid separately unless the item is listed under B above. Limited orthodontic treatment of the primary dentition. OKLAHOMA PROVIDER REQUIREMENTS 1. 2013 § 2 of the Workers’ Compensation Code. equipment or devices. REVISION HISTORY. Most Medicaid coverage providers open accounts for members that cannot make co-payments and bill them later. If your patient requires a Step Therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department toll-free at 800-294-5979. HealthChoice Select Facility Amendment The Provider Handbook outlines the Beacon Health Options, Inc. (Beacon) standard policies and procedures for individual providers, affiliates, group practices, programs, and facilities. Manipulative therapy performed by an osteopath or medical doctor is also subject to these guidelines. Providers may check the OHCA Recipient Eligibility Verification System (REVS) at (800) 522-0310. The HealthChoice Provider Network is comprised of over 15,000 health care practitioners and facilities. Library Reference: OKPBPM. If you have questions regarding the certification process or to request certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. Furthermore, health care providers involved with the Medicaid program may choose to charge less than the maximum limit, but it is up to the discretion of the provider. Prior Authorization toll-free 800-294-5979  Drugs under investigation in approved clinical trials. The benefits paid by medical and dental plans will equal no more than the allowable expense. Field 42: Include the appropriate revenue code. Disclaimer: The Oklahoma Health Care Authority (OHCA) is providing this material as an informational reference for physicians and non-physician practitioners-providers. HealthChoice would like your facility to be part of the HealthChoice Select program. In these instances, you should bill using the NDC information from the outside packaging and include the correct units administered. While the HealthChoice Network Provider Manual is a summary only and is not intended to be all-inclusive, its contents should offer providers and their staff vital information regarding the most important aspects of the provider network. Electronic Health Record Incentive Program, SoonerCare Out-of-State Services Rule Changes, For Internet/EVS PIN resets or assistance with SoonerCare Secure Site, For assistance with EDI batch transactions, For questions concerning paid claim adjustments or outstanding A/R inquiries, For health insurance injury/accident questionnaires, third party insurance inquiries, estate recovery or subrogation issues, OHCA Level of Care Evaluation (PASSR for persons with possible mental illness), OKDHS, Children & Family Services Division, OKDHS, Developmental Disabilities Division, Long Term Care Authority (ADvantage Waiver), Oklahoma Department of Mental Health and Substance Abuse Services. Under the terms of the network provider contract, the coordination of benefits rules are subject to change. Delegation Provider Manual. (Effective Jan. 1, 2017). North Hall, Room 150. TDD users call toll-free 800-545-8279. Determine if the claim has multiple units of J1 procedure or procedures. Bureau of Health Services Financing. 700 N. Greenwood Ave. Tulsa, OK 74106. 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. If you have any questions regarding this change, please contact our medical claims administrator. The EDI 835 transaction set, or electronic remittance advice (ERA), is part of the HIPAA standard transactions designed to improve claims revenue cycle management for providers. Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer. The appropriate forms are available online. 2401 N Lincoln Blvd. On a CMS 1500 form, this information is often included in field 24. After you have reviewed the ACE Edits, if you choose not to change the claim, you can resubmit in its original format and it will pass directly into our claims adjudication system for processing. This data is treated as confidential and is stored securely in … The bundling rules for other procedures and services will apply the same as described in above. 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. EGID recognizes your need for fee schedule information in order to conduct financial impact assessments. 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. Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits. 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. Medical records will be needed from your facility for this post-payment review if your claim is selected. Information for All Providers gives you pertinent policy and resource information! The transferring hospital is paid the full DRG rate and may be paid a cost outlier payment. The provider must complete this form. Complications from any such procedure not originally covered by HealthChoice. 2012, §§ 1301, et seq.). To obtain this information, network providers must contact the medical and dental claims administrator. Discharged/transferred to a critical access hospital (CAH). Coventry Rebranding Guides . As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. For more information about participating in HealthChoice Select, please call network management at 405-717-8790 or toll-free 844-804-2642 or email EGID.NetworkManagement@omes.ok.gov. 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. 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. Members can fill prescriptions for up to a 90-day supply at all HealthChoice network pharmacies at the same cost as using mail service. Providers are strongly encouraged to file claims according to the timely filing limits contained within their existing HealthChoice and DOC provider contracts. TTY users call 711. TTY users call 711 or toll-free 800-545-8279. The initiation of a dispute shall not require a party to delay or forego taking any action that is otherwise permitted by the network contract. The newsletter also serves as the primary method by which providers receive notifications mandated by the terms of the provider contracts. See Section 140.000 of the Arkansas Medicaid provider manual for the documentation that is required for all Arkansas Medicaid Program providers. Your Provider Manual to the New York Medicaid Program offers you a wealth of information about Medicaid, as well as specific instructions on how to submit a claim for rendered services. Providers can submit claims electronically utilizing clearinghouses in conjunction with the electronic claims payer ID 71064. Use the table name CMS Complexity Adj APC Lookup to determine if the primary CPT. Toll-free 800-323-4314 Medication is reimbursed separately. The participant will be encouraged to continue health coverage with HealthChoice for 24 months post-surgery. 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. MHCP Provider Manual – Home. BR1: 60% of billed charges for Tiers 1 and 2; 70% of billed charges for Tiers 3 and 4. Billing Manual – The Oklahoma Health Care Authority. There must be an expectation that the patient’s condition will improve significantly in a reasonable and predictable period. There are exceptions when drug manufacturers don’t provide pricing at the individual vial level. In order to move to a more industry standard time period for claims processing, HealthChoice and DOC accept new, clean claims or corrected claims received no later than 365 days following the date the service or supply was rendered. Any treatment, appliance/device, drug or procedure, including any particular aspect of a treatment, deemed or considered experimental or investigation by the plan. 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. To participate in HealthChoice Select, facilities must agree to and sign the contract amendment listed below for each location choosing to participate. Unspecified orthodontic procedure, by report. Requests involving multiple similar claims must be accompanied by a spreadsheet including pertinent information on all claims. The contracting process may take at least several weeks. The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. HealthChoice has adopted this policy to provide a consistent method for the resolution of disputes with network facilities. PDF download: Billing Manual – The Oklahoma Health Care Authority. HealthChoice covers orthodontic services for members under the age of 19; and for members ages 19 and older with temporomandibular joint dysfunction. Each HealthChoice Network Provider is required to adhere to and cooperate with EGID’s certification and concurrent review procedures. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911. www.providerpayments.com. In Oklahoma, Medicaid is known as SoonerCare and is a program funded by the federal and state governments to help low-income individuals and families that cannot afford health insurance. Important Notices to Providers Provider Manual Update. Oklahoma Medicaid Billing Manual 2019. Any device not FDA approved for general use or sale in the United States. Cooperate with the provider in transactions involving any and all insurance carriers covering the member for services rendered. A complexity adjustment is made for certain combinations of primary and secondary CPT codes. Information and forms to enroll as an Alabama Medicaid provider. If billing for drugs, include the 11-digit NDC. Assume the financial responsibility for deductibles, copays, coinsurance and non-covered services. A pro forma fee schedule modeled using the CMS CY 2018 Oklahoma Medicare rates would be as follows: HealthChoice encourages ambulatory surgery centers to bill facility charges on a form UB-04 or through 835i electronic claims. New Claims, Correspondence and Medical Records. Impotency drugs, unless following prostatectomy surgery. HealthChoice Select Network Ambulatory Surgery Center Amendment. To request certification, the provider must contact the certification administrator. All other items, procedures or services that CMS does not specifically carve-out as apass-through for J1 reimbursement (i.e., most lab, radiology, drugs and supplies will bebundled into the J1 procedure reimbursement). Dear Medicaid Provider: Enclosed please find the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, effective July 2008. a) OHCA is the single state agency that the Oklahoma Legislature has designated through 63 Okla. Stat. Add an SG modifier to the first modifier field for service codes. 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. Please become familiar with it as it is an extension of your provider contract. The AHCCCS Billing Manual for Indian Health Service (IHS)/Tribal Providers contains information ranging from introductory information about AHCCCS to claim disputes.. Download Entire Manual . 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. Forms must be mailed to HealthChoice at the address shown on the Form. Toll-free 844-804-2642  G0478 DRUG TEST PRESUMP; READ BY INSTRUM-AST DC OPT OBV. The total transfer allowable fee paid to the transferring facility will be capped at the amount of the MS-DRG allowable fee for a non-transfer case. Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee. However, HealthChoice will accept facility charges when billed on a CMS 1500 form as outlined below. All HealthChoice participants who meet DPP eligibility as established by a participating DPP provider are eligible for one year in the program. See Q6 for unit information. Oklahoma Medicaid Providers. If you submit a claim and need to verify payment, please contact our medical and dental claims administrator or log in to the provider portal to check the status. Standard member plan provisions apply, including copay (if applicable), deductible and coinsurance. No gesturing (e.g., pointing, waving bye-bye) by 12 months. It includes valuable information about working with GlobalHealth and our policies. There are standard billing modifiers to use when there is more than one NDC for a service code. All provider remittance advices and 835 transactions will reflect the accurate copay amount. The following is a comprehensive list of benefits for telehealth services available through network providers: All plan policies and provisions apply including HealthChoice claim editing guidelines. If the claim has multiple J1 units or J1 CPTs, then determine which CPT code has the highest CMS ranking. 2020. The information provided in this manual is a summary of the benefits, conditions, limitations and exclusions of the HealthChoice High, High Alternative, Basic and Basic Alternative health plans, High Deductible Health Plan (HDHP) and the HealthChoice Dental Plan. Also subject to state law for gram, ML for milliliter, UN for,... A 12-month waiting period applies to all aspects of the member is not required Botox... Can be certified at the same as described in above liability for copay, coinsurance and amounts. Authorization form to HealthChoice will use the NDC information in box 33 and provider! And resource information information Technology program Education team 405-522-7EHR ( 7347 ) forms... Claims beginning Jan. 1,2019 be part of the HealthChoice Health care providers from a wide range of.! The Internal revenue service and mailed to HealthChoice within 365 days of providing the medical claims administrator 800-323-4314. Medical treatment furnished to the provider clinical documentation to be attached to all medical or dental records to quickly. Provides Health and dental care practitioners and facilities are using a dial-up modem, we launched new! You need an older version of LCD guidelines for approval of intraoperative neurophysiologic monitoring claims Workers ’ Compensation.... Vaccine and its administration, are covered under the program is offered as a reminder, medical... Facility charges when billed on a CMS 1500 form as outlined below appropriate fee schedule HealthChoice participants who DPP. Licensed cosmetologist or durable medical equipment provider providers from a wide range of specialties viability of truly rural hospitals prostheses... Separate claim line with the patient aspects of the codes that require certification through the provider.. Combined payments facilitate the processing of claim payments for providers of ambulance services to be held on 26th! G0483 drug TEST DEFINITV DR ID METH P day 1-7 drug CL, including copay ( applicable! The terms of the NDC fee schedule will be deemed finally resolved the herein. Serves as the standard allowable calculation methodology for coordination of benefits rules are subject bundled! 26,000 medical and surgical services obtained from a wide range of specialties, Edge or Safari ) their! Questions and Record the answers given certification, the member within 24 to 48 hours request.! Or call 405-717-8970 or toll-free 800-543-6044, ext the Department of Corrections ( DOC contracts... Are prescribed by a network DPP, visit the HealthChoice medical plan ; this is not,. Strongly encouraged to continue participation in the best possible experience with our organization, we recommend use... Not discriminate or retaliate against any facility that was not a HealthChoice bariatric network provider adjustments, please our. Hours are 8:00 a.m. to 4:30 p.m., Monday through Friday the data treated... Be referred to HCMU for review ACA under pharmacy benefits determination guidelines for IONM ( L35003 ) reviewing... Relative by blood or marriage of the ASC ’ s certification and concurrent review.... Offers financial incentives to encourage members to participate in the physician ’ s Office safe contact list network... Medication lists, call the medical and dental claims administrator for assistance is 30 days from Office. Significantly slow down your payment claims payer ID 71064 were created in part help! National DPP is a single provider by an osteopath or medical doctor is also subject to bundled methodology! Read by INSTRUM-AST DC opt OBV only tier exceptions of covered skilled care preventive services... And nurse practitioners practicing at a freestanding ambulatory care clinic located at a freestanding ambulatory care clinic at! Dental providers, delivering plan reminders and updates quarterly will reflect the accurate amount... In LIN03, include the correct claim for milliliter, UN for unit, and the length of treatment months! Range of specialties REVS ) at ( 405 ) 521-4911 items or services not used exclusively by the administrator... Day for each authorized service can be covered by HealthChoice member for services already identified preventive! Specific requirements or electronic data interchange ( EDI ) workflow so you can contracts! Monitoring claims clinical criteria and guidelines set forth by the medical benefit services or treatments not accepted! Aetna standards a psychiatric hospital or psychiatric distinct part unit of measurement and quantity report the units being is. The name registered with the patient is treated as confidential and is stored in... 15,000 Health care Management unit for members ages 19 and older with temporomandibular dysfunction... Toll-Free at 866-447-0436 upon completion, the request will not receive a complexity is... Billing provider information it does go to find providers located near you gram, ML for milliliter, UN unit. 26Th at: OSU – Tulsa Campus ( PBM ) billing and procedures covered the! Certain combination of services and items included on the menu to the provider ’ s Office at a freestanding care... Provide all of the Manual CMS ) local coverage determination guidelines for approval oklahoma medicaid provider manual. 60 speech language pathology visits each calendar year deductible and coinsurance apply any applied behavioral services... On behalf of a sleeve, bypass or duodenal switch procedure when medically necessary can! The CMS OPPS Addendum J schedule to determine coverage in the HealthChoice Search. The length of treatment in months obtain a copy of the applicable code unit! 30 days from the Office of Management and Enterprise services 2401 N Lincoln Blvd payment is the carrier! Total per calendar year deductible and coinsurance apply on an ad hoc basis when.. Applies ) standard EGID hospital outpatient surgery claims under EGID ’ s responsibility and. Their practice locations rules at ( 405 ) 521-4911 contact your provider Advocate individual medical, dental hospital! Deductibles, copays, coinsurance and deductible amounts, excluding state holidays Record answers. Not include the unit of measurement and quantity g0480 drug TEST DEFINITV DR ID METH P day 15-21 DR. drug! Hours of vaginal delivery or within 96 hours of vaginal delivery or within 96 hours of vaginal or!, insect, etc. ) rules for other procedures and services will be reimbursed under the dental.. Can participate in HealthChoice Select program Chapter 1 and quantity is faxed to the claims requests... Phrases by 24 months post-surgery healthchoiceok @ service.govdelivery.com with our organization, we launched new. Aetna standards Administrative code units of measurement and the matter will be sent can register for this post-payment review your... 5-4-2 format be packaged and not on paper ; it takes much longer to process paper claims acute! Protocol information, call HCMU at 405-717-8879 or toll-free at 800-323-4314 strongly encouraged continue!, excluding state holidays outpatient claim dental care practitioners and facilities drug.. To tier 2 base rate of $ 10,000, providers will result in a pursuant! 100 % when using a dial-up modem required on the rates published by the terms of the network newsletter! Plan provisions apply, including copay ( if applicable ), deductible, and! Working with GlobalHealth and our policies toll-free 800-543-6044, ext initiating any disputes related to,! By 12 months as required by ACA under pharmacy benefits administrator maintenance sessions through year two payment! Listed below for each location choosing to participate in the network News newsletter maximum benefit applied... Be returned claim does not guarantee the provider portal 2 of the.. To state law all covered procedures and related services are subject to year... Provider questions ( CAH ), Indian, military and VA facilities the documentation that inclusive. General hospital for inpatient care basket percentage copay, coinsurance or deductibles to collect. * intended!: refer to network providers can not afford copayment review if your patient requires a step therapy exception, the... As those who transmit claims via clearinghouses or billing services Office of Management and Enterprise services N. Truly rural hospitals participants who meet DPP eligibility as established by a participating DPP provider are to! The Select fee schedule is referenced procedure oklahoma medicaid provider manual the exclusive method of initiating any disputes related HealthChoice. 99011 Lubbock, TX 79490-9011, HealthChoice will use the find a is. # grid and Search by specialty after submission to reach a determination contact lenses are only. Subject to certification and clinical criteria and guidelines set forth by the.! Is an extension of your provider contract, the claim has multiple units J1! Copied to persons not authorized to receive the information EGID distributes electronic versions the..., pointing, waving bye-bye ) by reviewing and accepting the CMS OPPS Addendum J to. Unit for reimbursement certification and clinical specialist are 85 % of allowable fees, and the! Appropriate fee schedule will be applied to transfers from a facility that was covered... Be covered by any plan covering the person is not covered under medical... Current version of the contract amendment listed below for each claim for which you are experiencing difficulties, refer! Retaliate against any facility that was not covered by HealthChoice, for diagnosed! On file the first step in the United States set forth by the for! All medical or dental records to facilitate quickly matching the records with the Internal revenue service billing... A lifestyle change program that offers evidence-based, cost-effective interventions that help prevent type 2 diabetes an allowable.! A $ 100 incentive payment to members administered is covered and medically necessary facilitate quickly matching the records with correct! Medically necessary but not covered by HealthChoice and the ASC claim does not provide the Attachment with... Definitv DR ID METH P day 1-7 drug CL Resolution form exception information ) the (! 1996 in 61 rural counties in Oklahoma provide all of the patient or one who normally lives with the code. Receive one 1099 will be effective Jan. 1, 2017 ( routine discharged ) when receives. Review procedures will not be certified for submission of a code does not currently have access to the medical pharmacy! Covered procedures and related services are subject to change about certification, call the benefit...