Fall 2015
IN THIS ISSUE
• Fee Schedule Updates
• DRS Fee Schedule Update Effective June 30 • Changes to Remittance Advices and ClaimLink • HealthChoice FOCUS Plan
• HealthChoice Select Provider Network • ICD-10 Quick Start Guide for Providers • Outpatient Reimbursement Changes
• Modifier 59 Clinical Editing Changes Will Effect Reimbursement • Preventive Services Changes
• Submit Only Current Network Provider Contracts
• Update to Laboratory Urine Drug Screenings and Confirmations • Changes in Speech Therapy Coverage for 2016
• Inpatient Discharge Status Codes • Approved Qualifiers for UB-04 Forms
• New Certification Rules for Blepharoplasty and Related Procedures • Always Refer to Network Providers
• Social Media Presence • Attention All Providers
• New Coverage for Telehealth Services • HIPAA 278 Transactions Available in 2016 • CVS/caremark Transition
• Help HealthChoice Members and Dependents be Tobacco-free • Network Provider Contact Information
NEWS
ee Schedule Updates
stated in the summer edition of the Network News, HealthChoice and the Department of Corrections OC) have updated their fee schedules for CPT/HCPCS, Outpatient Facility (OP), Ambulatory Surgery
nter (ASC), American Society of Anesthesiologists (ASA), American Dental Association (ADA), MS-RG, and MS-DRG LTCH codes effective for charges incurred on or after Oct. 1, 2015.
Be aware that HealthChoice and DOC update the CPT/HCPCS, outpatient hospital, ASC, ASA, and ADA fee schedules quarterly.
The next quarterly fee schedule update will be for charges incurred on or after Jan. 1, 2016, for CPT/HCPCS, OP, ASC, ASA, and ADA codes.
The American Medical Association may periodically change, add or delete procedure codes throughout the year. When these modifications occur, HealthChoice and DOC will review its fee schedule as soon as possible and make any necessary changes. Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis when needed.
Fee schedule updates are reported in each quarterly issue of the Network News. If you need specific codes and Allowable Fees affected by these updates, please visit our website at
https://gateway.sib.ok.gov/feeschedule and view or download the latest fee schedule addendum.
If you have questions or need additional information, please contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter. Email inquiries can be sent to
EGID.NetworkManagement@ omes.ok.gov or [email protected].
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DRS Fee Schedule Update Effective June 30
The Department of Rehabilitation Services has updated its fee schedule for charges incurred on or after June 30, 2015.
If you have any questions, please contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter, or send email inquiries to
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Changes to Remittance Advices and ClaimLink
Maintaining confidentiality is especially important to patients seeking treatment for sensitive issues and improvements in our privacy processes are made on an ongoing basis.
In order to better maintain patient confidentiality, HealthChoice, the Department of Rehabilitation Services and the Department of Corrections will remove the “Code” header and the “Code Description” from “Remittance Advices” and “ClaimLink” for all claims processed on or after Jan. 1, 2016. The certification administrator will also remove all references to coding/description from all communications.
For additional information, please contact the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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HealthChoice FOCUS Plan
HealthChoice FOCUS is a new plan that will be available effective Jan. 1, 2016, to pre-Medicare former employees and surviving dependents in the designated ZIP code service areas of Canadian, Cleveland, Comanche, Garfield, Grant, Logan, McClain, Oklahoma, Payne and Stephens counties.
The HealthChoice FOCUS Provider Network is comprised of clinically-integrated providers who are committed to a collaborative approach to care and are affiliated with Oklahoma Health Network (OHN), which includes the following groups:
• Comanche County Health Partners (Lawton)
• INTEGRIS Health Partners (Oklahoma City Metro and Enid) • Duncan Health Partners (Duncan)
• Norman Physician Hospital Association (Norman and Moore) • Stillwater Medical Center (Stillwater)
Please note that not all providers contracted with the HealthChoice Provider Network will be participating in the FOCUS Provider Network. The HealthChoice website, as well as the OHN website, will have links to the providers participating in the new network. HealthChoice FOCUS members will only receive Network benefits when they use a HealthChoice FOCUS Network Provider. If you have not also contracted with OHN for the HealthChoice FOCUS plan, any HealthChoice FOCUS claims will process as non-Network claims.
Please share this information with your scheduling staff so they do not inadvertently schedule appointments for FOCUS plan members if you are not a member of the OHN network.
For more information, visit the HealthChoice website at www.healthchoiceok.com. Under the “Current News” heading on the main page, there is an article that further explains the benefits of the HealthChoice FOCUS plan. You can search the “FAQ” section for more information, and under the “Find a Provider” tab, you can search for HealthChoice FOCUS Network Providers.
Questions regarding claims, eligibility or benefits should be directed to the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter. Questions regarding HealthChoice FOCUS Network Providers should be directed to OHN Customer Service at 1-405-652-1041 or toll-free 1-855-445-1471. You can also visit their website at
www.ohnonline.com/focus.
HealthChoice Select Provider Network
A public hearing was held on Sept. 30, 2015, to discuss proposed amendments to HealthChoice and Department of Corrections contracts to allow bundled payments for select procedures under the HealthChoice Select Provider Network.
For more information, please visit our website at www.healthchoiceok.com/Providers.
If you are interested in contracting with the HealthChoice Select Provider Network, please contact Teresa South at [email protected] or by phone at 1-405-717-8627.
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ICD-10 Quick Start Guide for Providers
An ICD-10 “Quick Start Guide” has been posted to the “ClaimLink” portal. The “Quick Start Guide” gives step-by-step instructions for entering claims with ICD-10 diagnosis codes using “ClaimLink,” and includes screen shots to help guide you through the process. For additional information, please visit our website at
www.healthchoiceok.com and select “ClaimLink” in the top menu bar and then select “ClaimLink for
Providers.”
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Outpatient Reimbursement Changes
Proposed changes to the outpatient reimbursement will be discussed at the public meeting on Oct. 28, 2015. For more information, please visit our website at http://ok.gov/sib/Providers/index.html and select “Proposed Changes for Outpatient Reimbursement” in the “Announcements” box on the right side of the screen.
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Modifier 59 Clinical Editing Changes Will Effect
Reimbursement
For charges incurred on or after Jan. 1, 2016, clinical editing for modifier 59 will be applied with the appropriate modifiers. These modifiers are used only for tracking and reporting purposes.
b. PO – Surgeries, procedures and/or surgeries provided at off-campus provider-based outpatient departments
c. XE – Separate encounter, a service that is distinct because it occurred during a separate encounter d. XP – Separate practitioner, a service that is distinct because it was performed by a different
practitioner
e. XS – Separate structure, a service that is distinct because it was performed on a separate organ/structure
f. XU – Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Network providers can model clinical editing through “ClaimLink.” Go to
www.healthchoiceok.com/providers and select “ClaimLink.”
For more information or if you have questions regarding this change, please contact the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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Preventive Services Changes
For charges incurred on or after Jan. 1, 2016, HealthChoice will cover two preventive services visits per calendar year (CPT codes 993XX) at 100 percent of the Allowable Fee when members use Network Providers. This change is for all members and dependents ages 18 and older.
Once a patient has utilized their preventive services benefit or is not eligible for a preventive services visit, prostate specific antigen tests, mammograms, immunizations for adults and children, and additional services will be subject to plan provisions, deductible and coinsurance.
Benefits for implantable rods or IUD insertions and removals will be updated to cover one procedure every three calendar years for women ages 18 and older. When all plan provisions are met, these preventive services will be covered at 100 percent of the Allowable Fee when members use Network Providers. For a complete list of changes, visit our website at www.healthchoiceok.com after Jan. 1, 2016.
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Submit Only Current Network Provider Contracts
Please be sure you submit only the most recent versions of the HealthChoice, Department of
Rehabilitation Services (DRS) or Department of Corrections (DOC) contracts. Outdated contracts will be returned to the provider which will delay the processing of the provider’s Network contract. The most current versions are always available online at the website addresses listed below.
DRS Contracts are available at gateway.sib.ok.gov/DRS/Contracts.aspx. DOC Contracts are available at gateway.sib.ok.gov/DOC/Contracts.aspx.
If you have any questions or are unsure which contract to use, contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter. Email inquiries can be sent to
EGID.NetworkManagement@ omes.ok.gov.
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Update to Laboratory Urine Drug Screenings and
Confirmations
For all charges incurred on or after Jan. 1, 2016, HealthChoice and the Department of Corrections will cover medically necessary laboratory urine drug screenings one time per day, subject to plan policies and provisions.
If you have questions regarding this change, please contact our medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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Changes in Speech Therapy Coverage for 2016
Speech therapy will be considered medically necessary for restoring existing speech lost due to disease or injury. Therapy must be expected to restore the level of speech the member had before the disease or injury. It is not covered for treatment of learning disabilities or birth defects. The plan maximum is 60 speech language pathology visits each calendar year. Certification through the HealthChoice Health Care Management Unit is required for members ages 17 and younger. Certification is not required for members ages 18 and older.
For charges incurred on or after Jan. 1, 2016, speech therapy services will also be considered
medically necessary for assessment and treatment of the diagnoses of pervasive developmental disorders (PDD) when the member meets any of the following criteria:
1. Any loss of any language at any age;
2. No two-word spontaneous (not just echolalia) phrases by 24 months; 3. No babbling by 12 months;
4. No gesturing (e.g., pointing, waving bye-bye) by 12 months; or 5. No single words by 16 months.
A request for a speech therapy evaluation for members 17 and younger must include a copy of the prescription or referral from a physician with documentation of the diagnosis. Requests for subsequent speech therapy visits must include a treatment plan from the speech pathologist that lists specific measurable goals, and the expected amount, frequency and duration for therapy. There must be an
expectation that the patient’s condition will improve significantly in a reasonable and predictable period of time. If at any point in the treatment it is determined the expectations will not be met, services will no longer constitute covered speech language pathology services. If the patient’s response to treatment is determined to be insignificant or at a plateau, continued coverage of speech services will be excluded. For additional information, please contact the health care management unit. Refer to “Network Provider Contact Information” at the end of this newsletter.
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Inpatient Discharge Status Codes
Effective Jan. 1, 2016, discharge status codes 03, 62 and 63 will be added to HealthChoice and Department of Corrections transfer payment processes. All existing discharge status codes remain the same.
If you have questions regarding this change, contact the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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Approved Qualifiers for UB-04 Forms
HealthChoice, the Department of Corrections and the Department of Rehabilitation Services will recognize the NUBC approved qualifiers “9” and “0” to denote which revision of ICD codes are required to be
reported on claims. Using form locator 66 on the UB-04 form, “9” designates the use of ICD-9 codes and “0” designates the use of ICD-10 codes. For all claims incurred on or after Oct. 1, 2015, ICD-10 codes are required. The new UB-04 billing guide is available on our website at www.sib.ok.gov/Providers/.
If you have questions regarding this change, please contact the medical and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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New Certification Rules for Blepharoplasty and Related
Procedures
Beginning Jan. 1, 2016, HealthChoice will be changing the certification criteria for blepharoplasty, repair of blepharoptosis, repair of brow ptosis and correction of lid retraction. After Jan. 1, certification requests for these procedures must include color photographs and the results of visual field tests. Following is a list of the new certification requirements:
• Blepharoplasty and repair of blepharoptosis will require two frontal color photographs, untaped and taped, that show the visual field obstruction and visual field correction. Also, two central field tests, one taped and one untapped.
• Repair of lid ptosis will require two color photographs, one showing the eyebrow below the bony superior orbital rim, and one with the brow taped up that eliminates the visual field defect. Also, two central field tests, one taped and one untapped.
• Correction of lid retraction will require photographs to document the pathology. Also, a list of tried and failed conservative treatments must accompany the certification request.
Certification requests, along with color photographs, can be sent to: APS HealthCare
55 N. Robinson, Ste. 600 Oklahoma City, OK 73102
Requests can also be sent by secure email to
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Always Refer to Network Providers
It is required by the terms of the HealthChoice and the Department of Corrections contracts 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, please contact network management. Refer to “Network Provider Contact Information” at the end of this newsletter. Email inquiries can be sent to
[email protected] or [email protected].
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Social Media Presence
We are happy to announce that the Office of Management and Enterprise Services (OMES), the parent agency of the Employees Group Insurance Department, has launched a Facebook page and a Twitter profile as a new avenue to keep everyone informed of OMES events, accomplishments and new products. Please follow us on Facebook at www.facebook.com/OklahomaOMES, and on Twitter at
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Attention All Providers
Providers will receive one 1099 for each tax identification number (TIN). If you share a TIN with other providers, there will still be only one 1099 sent. This form will be addressed to the name registered with the Internal Revenue Service and mailed to the address indicated on your W-9 form.
If you have questions regarding your 1099, please contact our health and dental claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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New Coverage for Telehealth Services
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 use of a telecommunications system may be substituted for an in-person encounter for specific services.
For charges incurred on or after Jan. 1, 2016, HealthChoice and the Department of Corrections will recognize some professional services submitted with appropriate CPT or HCPCS codes along with the telehealth modifier “GT” as follows:
99441 Phys/QHP Telephone Evaluation 5-10 min 99442 Phys/QHP Telephone Evaluation 11-20 min 99443 Phys/QHP Telephone Evaluation 21-30 min
99444 Phys/QHP Online Evalution & Management Services G0406 F/U IP CNSLT LTD Phys 15 with PT Via Telehealth G0407 F/U IP CNSLT Intermed Phys 25 min PT Via Telehealth G0408 F/U IP CNSLT CMPLX Phys 35 Min/> PT Via Telehealth G0425 Telehealth Consult ED/IP 30 min with PT Via Telehealth G0426 Telehealth Consult ED/IP 50 Min with PT Via Telehealth G0427 Telehealth Consult ED/IP 70 min/> PT Via Telehealth
All services must meet medical necessity guidelines and all plan provisions. For more information, please contact the medical claims administrator. Refer to “Network Provider Contact Information” at the end of this newsletter.
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HIPAA 278 Transactions Available in 2016
The Employees Group Insurance Department will be accepting HIPAA X12N version 5010 278 – Health Care Services Review – Request for Review and Response Transactions in 2016.
The 278 facilitates the exchange of information between providers and review entities for: • Admission certification reviews;
• Referral reviews;
• Health care services certification reviews; • Extend certification reviews;
• Certification appeal reviews;
• Reservation of medical services; and • Cancellation of service reservations.
The 278 transaction is one of the standard transactions covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for the health care industry to achieve administrative cost savings with electronic data interchange (EDI). It is also one of the transactions covered under section 1104 of the Patient Protection and Affordable Care Act for the use of operating rules to support implementation of HIPAA standards.
Health care service providers are not required to utilize the standard transaction; however, if you choose to submit EDI transactions, the standards and operating rules must be followed.
These transactions will be accepted in batch mode from Emdeon, and Emdeon will return responses to providers.
For more information regarding the format of the 278 transaction and for implementation assistance, refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC
X12N/005010X217, Health Care Services Review – Request for Review and Response (278)
Implementation Guide. The guide is available through Washington Publishing Company,
www.wpc-edi.com.
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CVS/caremark Transition
HealthChoice has chosen CVS/caremark to administer its pharmacy benefits starting Jan. 1, 2016. This change will result in formulary changes for HealthChoice members due to the transition from Express
Scripts (ESI) to CVS/caremark.
Pre-Medicare Health Plan Members
Pre-Medicare members will be notified by mail in November if they are currently taking medications that will be excluded in 2016, or if they will be negatively impacted by a formulary change. This letter will also list the available Preferred alternative medications.
Prior authorizations that are currently in effect for pre-Medicare members will transfer from ESI to
CVS/caremark. Beginning Jan. 1, 2016, providers can contact CVS/caremark toll-free at 1-800-294-5979 to obtain prior authorizations on behalf of our members.
Medicare Supplement Health Plan Members
HealthChoice is terminating its Part D contract with the Centers for Medicare & Medicaid Services;
however, HealthChoice has contracted with CVS/caremark and its SilverScript Employer Prescription Drug Plan to provide Part D benefits to our members.
CMS does not allow prior authorizations to transfer between Part D contracts. As a result, HealthChoice Medicare supplement plan members who currently have a prior authorization through ESI must obtain a new one through CVS/caremark on or after Jan. 1, 2016. Members will be able to receive a transition fill for the first 90 days of the new plan year. After the transition fill, members and providers will be notified by mail that a new prior authorization is needed.
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Help HealthChoice Members and Dependents be
Tobacco-free
Quitting Is The Goal
HealthChoice is committed to better health, and a major part of that commitment is to continually focus on tobacco cessation. Please encourage HealthChoice members and dependents to quit tobacco for good by keeping them informed of the health risks and treatment options.
QUIT Program
Through a cost-sharing agreement with Oklahoma Tobacco Research Center, HealthChoice plan members and dependents ages 13 and older can receive five phone coaching sessions and up to 12
weeks of over-the-counter products, including gum, patches or lozenges, at no cost through the Oklahoma Tobacco Helpline (1-800-QUIT-NOW).
HealthChoice Preventive Services and Enhanced Tobacco Cessation
Benefits
HealthChoice members and dependents ages 18 and older can also receive one free annual tobacco cessation/tobacco-related disease counseling visit to a HealthChoice Network health provider (billing code: 99406); as well as two 90-day courses per plan year of prescription tobacco cessation products at no cost when they are received through a Network Pharmacy. Covered products include:
• Buproban 150mg SA Tabs • Bupropion HCL SR 150mg Tabs • Chantix 0.5mg and 1mg Tabs • Nicotrol 10mg Cartridge
• Nicotrol NS 20mg/m Nasal Spray
For more information, visit www.healthchoiceok.com.
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Network Provider Contact Information
HealthChoice Providers
www.healthchoiceok.comMedical and Dental Claims
HP Administrative Services, LLC P.O. Box 24870Oklahoma City, OK 73124-0870 Customer Service and Claims OKC Area 1-405-416-1800 Toll-free 1-800-782-5218 FAX 1-405-416-1790 TDD 1-405-416-1525 Toll-free TDD 1-800-941-2160
Pharmacy
Express ScriptsPharmacy Prior Authorization for Preferred/Non-Preferred or Brand/Generic Toll-free 1-800-841-5409
Other Pharmacy Prior Authorization Toll-free 1-800-753-2851
Certification
APS Healthcare P.O. Box 700005 Oklahoma City, OK 73107-0005 Toll-free 1-800-848-8121 Toll-free TDD 1-877-267-6367 FAX 1-405-416-1755HealthChoice Health Care Management Unit OKC Area 1-405-717-8879
Toll-free 1-800-543-6044, ext. 8879
HealthChoice Network Management
OKC Area 1-405-717-8790Toll-free 1-844-804-2642
DOC Network Management
https://gateway.sib.ok.gov/DOCOKC Area 1-405-717-8750 Toll-free 1-866-573-8462
DOC Medical and Dental Claims
HP Administrative Services, LLC P.O. Box 268928 Oklahoma City, OK 73126-8928 Toll-free 1-800-262-7683DRS Network Management
https://gateway.sib.ok.gov/DRS OKC Area 1-405-717-8921 Toll-free 1-888-835-6919DRS Medical and Dental Claims
HP Administrative Services, LLCP.O. Box 25069
Oklahoma City, OK 73125-0069 Toll-free 1-800-944-7938
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