Beginning June 2, 2010, HealthChoice Network Providers have online access to their Remittance Advices (RAs). You can view and print your RAs by accessing your secure provider account through ClaimLink.
The ability to access RAs electronically can help improve revenue cycle management by reducing the lag time between an Electronic Funds Transfer and receipt of the RA in the mail. Instant access to RAs can help speed your account reconciliation processes.
“We’re very excited our providers will have electronic access to RAs,” said Teresa South, Director of Provider Relations for HealthChoice. “This represents another step in the process of moving toward electronic communications with our providers. The electronic process will save time and money, and it’s also environmentally friendly,” she said.
The RAs available on the website look exactly like the hard copy versions you currently receive, and even though RAs are available on the website, HealthChoice will continue to mail hard copies unless you choose to go paperless. If you prefer to go paperless and stop receipt of paper RA’s, you must contact HP Administrative Services at 1-405-416-1800 or toll-free at1-800-782-5218. Please note that you will continue to receive paper RAs until mid-July when the paperless function goes into effect for those who have chosen to discontinue paper RAs.
You can access the online RAs by clicking ClaimLink in the left side menu. Adobe Reader is required to view the PDF documents. A Quick Start Guide is also available in the Resources section of ClaimLink.
For assistance or additional information, contact HP Administrative Services at one of the numbers listed above.
It has been determined that for a short time during 2009, some hospital* claims were incorrectly grouped using DRG 470. The error in the claims processing system has been corrected and the affected claims have been reprocessed. These claim corrections could result in additional payments to the hospitals or may create overpayments.
*Long term acute care facilities were not affected by this error.
Online claims filing is available for providers billing on a CMS 1500***. This new feature is available through ClaimLink. Online claim submission is a more efficient process that significantly reduces processing errors and improves turnaround time for claim payments. Claim status is available the next business day on ClaimLink. A Quick Start Guide that outlines the claim submission process is available through ClaimLink.
For additional training please contact Kelli Nichols at 1-405-416-1504. Provider Relations is also available to provide assistance at 1-405-717-8790 or toll-free 1-800-543-6044.
We welcome any questions or comments. If you are interested in on-site training, please call Provider Relations 405-717-8790 or 1-800-543-6044.
***This feature is not yet available for claims for anesthesia services.
Effective for all orthodontia services incurred on or after January 1, 2011, HealthChoice and DOC providers must bill as described below:
This is only a summary of the general use of orthodontia ADA codes which does not guarantee benefits under the plan. All policy provisions, exclusions, and limitations apply.
If you have any questions, please contact HP Administrative Services at 1-405-416-1800 or toll-free at 1-800-782-5218
* Be aware that beginning January 1, 2011, ADA codes D8670, D8680, and D8690 will not be covered by HealthChoice or DOC.
What you need to know: Providers should contract under the “billing” or “pay to” address reported to the IRS for their TIN. This is the same billing address reported on each provider’s W-9. Contracting multiple billing addresses under one TIN due to additional TIN/NPI combinations could result in claim payment issues.
We are now using the following claims matching logic to address such issues:
Claims will process as in network if they contain a contracted TIN/NPI combination in the following fields:
Institutional Claims – UB04
Non Institutional Professional/Outpatient Claims – CMS 1500
Outpatient Claims (ASC, Ambulance, IDTF, etc.) – CMS 1500
Dental Claims – ADA 2006
Providers who have multiple network contracts under the same TIN/NPI will have an additional match to the ZIP Code indicated in the fields described above. Multiple contracts generally occur when providers have multiple practice locations under the same TIN/NPI combination.
If the ZIP Code does not match the current ZIP Code listed in the provider’s contract, the claim will process in-network to the first in-network contract under the TIN/NPI combination.
This enhancement should eliminate erroneous out-of-network payments for claims that are submitted by providers under a contracted TIN/NPI combination.
Providers with multiple billing/pay-to addresses that use the same TIN/NPI could experience a consolidation of claim documents being received at the address listed in their first in-network contract. This would occur only when a provider has multiple contracts for the same TIN/NPI combination and the ZIP Code on the claim does not match the ZIP Code for the address listed in the first in-network contract.
The Centers for Medicare and Medicaid Services (CMS) has released the following guidelines for ICD 10 codes and updating the standards for electronic health care transactions to Version 5010. HealthChoice Providers will have to comply with these changes, so it is important that you begin preparing for these changes now.
Claims submitted after the implementation dates set by CMS will be denied. You will be able to resubmit these claims; however, it will result in reimbursement delays.
ICD-10 Codes
CMS has mandated that ICD-10 codes must be used by providers on all HIPAA transactions, including claims, with dates of service on or after October 1, 2013.
Version 5010 of the Standards for Electronic Health Transactions
On January 1, 2012, standards for electronic health care transactions will change from Version 4010/4010A1 to Version 5010. The current version does not accommodate ICD-10 codes and so Version 5010 must be in place before these codes become standard. The January 1, 2012 implementation date of Version 5010 will allow adequate time for testing before ICD-10 codes are required. Electronic health care transactions include claims, eligibility inquiries, and provider remittances.
Additional information about ICD-10 codes can be found on the CMS website at http://www.cms.gov/ICD10/
Certification by APS HealthCare is required for the following inpatient admissions and procedures even when HealthChoice is the second or third payor:
Helpful Hint:
When HealthChoice is the second or third payor, (Other group health insurance or Medicare primary) certification is required for the admissions and procedures listed above. This process helps protect both the provider and the member in the event the primary payor denies coverage or applies coverage exclusions or limitations. For example, the primary carrier denies a service that is covered by HealthChoice. If the provider did not request certification prior to the admission or procedure, HealthChoice may cover the service but a 10% penalty will apply to the provider even if the service meets certification requirements and is medically necessary as determined by OSEEGIB. This process will also be applicable when a member exhausts benefits under CMS and HealthChoice pays in the primary position and may pay any additional benefits.
The HealthChoice Health Care Management Division has updated its Certification Request Forms. These forms must be used to request certification for specific medical care for HealthChoice members. Providers must begin using the updated forms immediately. If you submit an earlier version of one of these forms, it will be returned with a request to complete and submit the updated form.
To access the updated forms click here.
For information about certification requirements, see Utilization Review in the HealthChoice Provider Manual.
HealthChoice requires that all non-emergency hospital admissions are certified at least three working days prior to the actual admission. Emergency hospital admissions must be certified within 24 hours (one working day) of the actual admission date, and holiday or weekend admissions must be certified the first working day following the date of admission. Please note that certification is required even if HealthChoice is the second or third insurance carrier.
Network Facilities are required to notify HealthChoice of inpatient hospital admissions based on parameters set in the HealthChoice contract. Facilities are also required to provide clinical information to help establish the medical necessity of all inpatient admissions. After a review of clinical information, inpatient hospital admissions are denied if medical necessity is not confirmed.
If certification is not initiated and approved within the time frame defined by the Plan, a 10% penalty is applied. If medical necessity is not established, the claim is denied.
To request certification and provide the clinical information needed to establish medical necessity, call APS Healthcare toll-free at 1-800-848-8121. You can also fax clinical information to 1-405-416-1755.
If you have questions about the certification process, please contact HealthChoice Provider Relations at 1-405-717-8790 or toll-free 1-800-543-6044.
On April 15th, HealthChoice discontinued its online claims resolution service. The online service was made available to members and providers last year during the Plan’s transition to its new claims administrator, HP Administrative Services; however, due to improved telephone response times and efficiency of claims processing, the online resolution service is no longer necessary.
For assistance with a claim, please contact HP Administrative Services at 1-405-416-1800 or toll-free 1-800-782-5218.
Institutional providers submit claims utilizing the UB-04 claim form. Effective March 26, 2010, institutional providers will be paid based on the 837 2010AB “Pay to” address instead of the 837 2010AA “billing” address.
You can verify the current billing address on record for your contract at the HealthChoice Provider Self Service web page at https://gateway.sib.ok.gov/providerselfservice.
This change for institutional providers is being made in an effort to enhance the accuracy of claims payments to these providers.
This change does not apply to non-institutional providers who submit claims using the CMS-1500 claim form. These claims will continue to be paid based on the 837 2010AA “billing” address. Future changes will also enhance payments to these providers.
See the related article for both provider types at the following link for additional details: http://www.sib.ok.gov/providers/#Billing.
The CPT/HCPCS and outpatient facility fee schedules for HealthChoice and DOC will be updated effective June 1, 2010, and will be available on the website at that time. Please continue to reference the Network Provider Home Page periodically for updated fee schedule information.
HealthChoice has denied some services on dental claims because of tooth numbers that are different from tooth numbers submitted on prior claims.
Unfortunately, the claims processing system did not recognize the tooth numbers, and in some cases, the system errors resulted in erroneous denials.
HealthChoice is working very diligently to resolve this system issue and will use this website to notify you when this issue has been resolved.
If you have questions about this issue, please direct them to Provider Relations at 1-405-717-8970 or toll-free 1-800-543-6044. Questions regarding the processing of a claim should be directed to HP at 1-405-416-1800 or toll-free 1-800-782-5218.
Many of you may already be aware that in August of 2008, HP acquired EDS Administrative Services, the HealthChoice health and dental claims administrator. Even though the acquisition took place during 2008, it wasn’t until recently that the name was officially changed to HP Administrative Services, LLC. All future communications sent to providers will use the new company name. Please note that while the company’s name has changed, all other aspects of its business remain the same. If you have questions regarding a health or dental claim, contact HP Administrative Services, LLC. at 1-405-416-1800 or toll-free at 1-800-782-5218.
Under the current HealthChoice benefit, an observation hospital stay, without room and board charges, that lasts longer than 24 hours is processed as an inpatient hospital stay. All inpatient hospital stays are paid based on the DRG fee schedule and require certification.
Effective June 1, 2010, HealthChoice is changing the way it pays for these services. An observation hospital stay, without room and board charges, that lasts longer than 24 hours will be processed as an outpatient service and paid according to the Plan’s outpatient fee schedule. All observation hospital stays must be certified with the exception of observation stays less than 24 hours without room and board charges.
Please contact Provider Relations if you have questions about the changes that will be implemented on June 1. Contact HP Administrative Services, LLC if you have questions about payments you receive for these services.
Dental implants that are approved by the Food and Drug Administration are covered by the Plan and eligible for payment. The name of the dental implant must be included on the claim form when claims are submitted with ADA codes D6010, D6012, D6040 and D6050.
The OK Health Program is a wellness initiative for current state employees to take advantage of certain health services free of charge. The following services are free to participants when using Network Providers:
Provider must file claims using an “OK” modifier with each CPT code on the CMS-1500 claim form. This will identify the services performed under the program and assure correct payment.
If you have questions, please contact the HealthChoice Provider Relations Division at 1-405-717-8790 or toll-free 1-800-543-6044.
You may have noticed that the Provider Remittance statements have been modified to print on both sides. The name of the provider and the HealthChoice claims address will appear on the first page as appropriate. Information about the processing of the claim is presented on pages two, three and four. The blue barcode sheet will appear on pages five and six and if a payment is made to the provider, the payment check will be on page seven. There will not be a change to the information that is contained on the Provider Remittance. The duplex remittance statement is intended to reduce our use of paper.
OSEEGIB is excited to announce that all Network Dentists can now file claims online through ClaimLink. ClaimLink is an online service available through each Network Provider website.
Many providers have already used ClaimLink to verify member eligibility and check the status of claims. Online claim submission is a much more efficient method of submitting claims. It significantly reduces processing errors and improves the turnaround time for claim payments. A presentation that outlines the online claims submission process is available once you log into ClaimLink. If you have additional questions, please contact HP Administrative Services, LLC. at 1-405-416-1800 or toll-free 1-800-782-5218.
For additional training please contact Kelli Nichols at 1-405-416-1504. OSEEGIB is also available to provide assistance at 1-405-717-8790 or toll-free 1-800-543-6044.
For security purposes, you must register to obtain a unique username and password to use ClaimLink. If you have previously registered for ClaimLink, it is not necessary to re-register to file claims online.
Institutional providers
Non Institutional providers (Providers utilizing CMS-1500 Claim Forms)
You may verify the current billing address on record for your contract at the HealthChoice Provider Self Service web page - https://gateway.sib.ok.gov/providerselfservice.
If the address listed does not exactly match the address you are now billing under, your claims will be paid as non-Network. To update the billing address on record for your contract, you should submit a completed Change Form with the correct information. The Change Form is available for download on the HealthChoice provider website at - http://www.sib.ok.gov/providers/Providers_Forms.asp.
Please submit your completed Change Form to Provider Relations either by email, mail, or by fax:
Via Email
oseegibproviderrelations@sib.ok.gov
Via Mail
HealthChoice
Attn: Provider Relations
3545 NW 58th, Suite 110
Oklahoma City, OK 73112
Via Fax
1-405-717-8977
We would like to apologize for the numerous letters that were recently mailed requesting certification documentation and the inconvenience this may have caused. The letters were produced on a line item level instead of a claim level which is why you received several letters for one claim.
If you received any of these letters, please follow the instructions at the bottom for fastest resolution. If certification was previously obtained from OSEEGIB, you may contact HP at 1-405-416-1800 or toll-free 1-800-782-5218.
OSEEGIB hereby clarifies the intent of Network Provider contract articles relating to certification/ utilization review requirements:
Effective January 1, 2010, as soon as an outpatient procedure or inpatient admission has been certified and approved, the provider has met the conditions of the contract, and the procedure can be performed immediately. It will not be necessary to wait the three-day period before services may be provided.
The HCPCS, ASA, ASC and outpatient facility fee schedules for HealthChoice have been updated effective January 1, 2010, and are available on the website. See the article below for information about updates to the CPT code fee schedule. Please continue to reference the Network Provider Home Page periodically for updated fee schedule information.
The Oklahoma State and Education Employees Group Insurance Board has updated its fee schedule to reflect the CPT code additions, deletions and verbiage changes which became effective January 1, 2010. However, for 2009 CPT codes which remain in effect for 2010, the Board will extend the 2009 fee schedule until such time as CMS determines when it will proceed with its fee schedule updates for 2010.
Provider Relations has been contacted by providers with questions about coverage for Consultation Codes. These questions have been generated by the Medicare/CMS decision to discontinue payment for the services designated by these codes effective 1-1-10. The consultation CPT codes include the inpatient codes (99251-99255) and office/outpatient codes (99241-99245). Since Medicare will not pay for the services reported by these codes in 2010, the HealthChoice Medicare Supplement Plans will not cover these codes beginning 1-1-10.
HealthChoice will continue to recognize these codes as valid for payment for the HealthChoice High Option, Basic, and S-Account Plans.
CPT and HCPCS codes have been added to the HealthChoice and DOC fee schedules effective 11-1-09 for the H1N1 Virus vaccine and its administration. These three codes are as follows:
As a reminder, the Utilization Review section of the Network Provider contract mandates that certification/authorization must be obtained before some specific services are rendered or the claims submitted for those services will be denied. If certification/authorization is subsequently obtained and medical necessity is established, a 10% penalty will be applied to the payment.
If you need additional information or you have questions, please contact Provider Relations at 1-405-717-8790 or toll free 1-800-543-6044.
In an effort to increase the efficiency and accuracy of claims processing, effective September 1, 2009, non-standard claims will no longer be accepted. All claims that are not submitted on the proper claim form, or forms that are incomplete, will be returned. Inappropriate claim forms include, but are not limited to superbills, copies of receipts, or printed reports generated from practice management software.
Visit the following web sites to access the appropriate claim forms or for more information on proper billing procedures.
Claim forms sent by FAX will no longer be accepted.
The FHH overpayments that were scheduled to be recouped from claim payments starting 9/1/09 are now in the process of being recouped. These adjustments are identified by the Accounts Receivable reason code “FHOV” which is located at the bottom of the Provider Remittance.
Please call HP at 1-405-416-1800 or toll-free 1-800-782-5218 if you have unresolved overpayment issues from FHH or to obtain details regarding the original claim payment(s) involved in the recoupment. The following are the phone prompts on the HP customer service call line which will connect you to the overpayment team for assistance:
We regret that there has been some confusion regarding certain HealthChoice dental benefits. We hope this will provide some clarification.
Dental Prophylaxis Coverage
HealthChoice covers dental prophylaxis treatments for children 0-12 years old (ADA code D1120) and for members 13 years of age and older (ADA code D1110). Two prophylaxis treatments are allowed per calendar year. All prophylaxis treatments must be billed on an 2006 ADA Dental Claim Form.
Coverage for Bitewing X-Rays
HealthChoice currently covers up to four bitewing x-rays per calendar year. The cost for bitewing x-ray services in excess of the maximum benefit , are the responsibility of the member.
The following codes are assigned by the American Dental Association for bitewing x-rays in its current Dental Terminology Code Book 2009-2010. All claims must be filed on an 2006 ADA Dental Claim Form:
D0274 – 4 bitewings
D0273 – 3 bitewings
D0272 – 2 bitewings
D0270 – 1 bitewing
The previous dental administrator applied this benefit, incorrectly, allowing eight bitewing x-rays per calendar year. Due to the initial confusion regarding the benefit for bitewing x-rays, HealthChoice continued to allow eight bitewings per calendar year for charges incurred before January 1, 2009.
HealthChoice has clarified this benefit discrepancy with the current dental administrator, HP, and effective for charges incurred on or after January 1, 2009, the correct benefit of four bitewings per calendar year is being applied by HP.
An article that sought to clarify the issue of coverage for bitewing x-rays appeared on the front page of the Spring Edition of the HealthChoice Provider newsletter, the Network News.
Fluoride Treatment Coverage
OSEEGIB covers fluoride treatments for children ages 0-12 (ADA code D1203). There is a limit of two fluoride treatment allowed per calendar year. Adult fluoride treatments (ADA code D1204) are not a covered benefit. All fluoride treatments must be billed on an 2006 ADA Dental Claim Form.
For Faster Processing of Dental Claims
For faster service for you, as a dental provider, please do not send things such as dental x-rays and molds with the claim or dental pre-determination unless they are requested by HealthChoice. This will also save you time and expense. HP, the dental claims processing administrator, currently receives many dental items that are not necessary for claims payment.
Oklahoma State Statutes require interest to be paid to providers when clean claims are not processed within 45 days of receipt. In accordance with this requirement, the Oklahoma State and Education Employees Group Insurance Board, through its third party claims administrator, HP is paying interest for claims that meet the criteria required in the State Statues.
Prospective interest payments began on April 8, 2009. All claims paid on or after that date included interest payments if the claim was not processed and paid within the mandated 45 day period.
Recently, retrospective interest payments were initiated. Providers were sent communication through the mail with instructions on how to initiate the process of receiving interest for older claims. The process of distributing retrospective interest is being handled in three phases.
Questions and Answers regarding interest payments can be found using the Interest Payment Questions and Answers link following this article.
Any additional questions you may have concerning interest payments should be directed to HP Administrative Services, LLC. at 1-405-416-1780 or toll-free 1-800-782-5218.
Interest Payment Questions and AnswersOrthodontic Services are paid by the Plan at the established benefit level when the banding has been performed. The orthodontist is expected to file a claim for the services performed at the time the service is rendered. The Plan does not pay claims based on payment installments.
A small percentage of Orthodontists are filing claims with future billing dates. Claims with future billing dates will not be accepted and will be denied.
If you have any questions regarding the processing and payment of claims for orthodontic services, please contact HP Administrative Services, LLC. customer service at 1-405-416-1800 or toll free 1-800-782-5218.
Need to report a technical issue? Contact the Web Master
