Under the current HealthChoice benefit, an observation hospital stay that lasts longer than 24 hours, with room and board charges, is processed as an inpatient hospital stay. All inpatient hospital stays are reimbursed based on the DRG fee schedule and require certification.
Effective June 1, 2010, HealthChoice is changing the way it reimburses for observation hospital stays with room and board charges.
Please contact HealthChoice Provider Relations at 1-405-717-8790 or toll-free 1-800-543-6044 if you have questions about reimbursement for observation hospital stays.
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 Smith 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.
You may verify the current billing address on record for your contract at the HealthChoice Provider Self Service web page - https://gatway.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 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 Administrative Services, LLC 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 will extend its 2009 CPT code fee schedule beyond 2-28-10. No updates will occur at this time. An exception to the extension applies to the 2010 CPT code additions and deletions which became effective on 1-1-10.
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.
Providers will be sent 1099 forms under the names registered by the Internal Revenue Service on the 1099 windows and as indicated on the W-9 forms. Only one 1099 will be distributed for each tax identification number (TIN). If multiple providers share the same TIN, only one 1099 will be prepared and sent. The 1099 is mailed to the address indicated on the W-9 form submitted to cover each provider sharing a single TIN.
The allowable for CPT code 41899 has been updated to $1,566 in an Ambulatory Surgery Center setting. The original fee schedule amount of $80 was not appropriate and we are taking this opportunity to correct the previous fee allowed by the Plan. The fee schedule that is included in the ASC contract (See Contracts/Appl in the menu at left) has also been updated to reflect the most current allowable for code 41899.
In addition to updating the fee schedule, claims reimbursed at the erroneous fee have been adjusted to allow the revised fee schedule. You will be notified of the adjustment through your Provider Remittance statements.
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.
Although the transition from the previous claims administrator to HP Administrative Services, LLC has been extremely difficult, there has been significant improvement with claims payment. Now, more than 70% of electronic claims are processed within one business day. However, much improvement is still needed in regards to the customer service being provided to HealthChoice members and providers. The extremely long hold times members and providers are experiencing when attempting to call HP Administrative Services, LLC does not meet the requirements stipulated in its contract with HealthChoice. HP Administrative Services, LLC has hired additional customer service representatives in an effort to reduce the hold time. HealthChoice will continue to monitor EDS’s progress in this area and apply financial penalties appropriately until it is in compliance with the contract.
For assistance with any outstanding claim issues, you can send an email containing the details of your issue to EDSResolution@sib.ok.gov. For security reasons, please include the member ID number in your email instead of the member's Social Security number.
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 Administrative Services, LLC 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 Administrative Services, LLC 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 D1100). 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 Administrative Services, LLC, 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 Administrative Services, LLC.
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 Administrative Services, LLC, 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 Administrative Services, LLC, 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 Administrative Services 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.
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