Summer Edition 2013 (PDF Version)
As of July 1, 2013, claims received with no EFT information on file are being denied and will not be processed until the information is received.
As mandated by HB1086, the Transparency, Accountability, and Innovation in Oklahoma State Government 2.0 Act of 2011, all payments disbursed by the Office of the State Treasurer must be made solely through Electronic Funds Transfer (EFT).
Claims processed on or after July 1, 2013, for providers who have not authorized EFT for their Tax ID Number (TIN), are being denied, regardless of the date of service, with explanation code 925, “Payment Delayed – no EFT info on file”. If you are a Network Provider and your claims are being denied, please submit EFT information via the Electronic Funds Transfer (EFT) Form as soon as possible.
- Practice groups that use the same bank account for multiple providers under the same TIN need to submit only one form to EGID along with a list of their affiliated providers.
- The EFT authorization form is good for all networks and locations under the contracted TIN/NPI combination.
The EFT authorization form for HealthChoice, Department of Corrections (DOC), and Department of Rehabilitation Services (DRS) Network Providers is available on the following links: http://www.ok.gov/sib/Providers/Provider_Forms/index.html https://gateway.sib.ok.gov/DOC/Forms.aspx https://gateway.sib.ok.gov/drs/Forms.aspx
Non-Network providers can contact our claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
Network Providers with questions, please contact Network Management at 1-405-717-8790, toll-free 1-800-543-6044, or send email inquiries to EGID.NetworkManagement@omes.ok.gov.
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The Office of Management and Enterprise Services (OMES) Employees Group Insurance Division’s (EGID) rule regarding the effective date for newborn coverage changed for charges incurred on or after Jan. 1, 2013. The new rule states that the effective date for newborns added to the plan is the first of the month of their birth. However, for the remainder of 2013, EGID will continue to allow newborns to be added the first of the month of birth or the first of the month following birth.
For charges incurred on or after Jan. 1, 2014, newborns must be added to coverage the first of the month of the child’s birth. Premiums must be paid for the birth month and when one or more eligible dependents are currently covered, the newborn must be added to the same coverage, unless there is proof of other group coverage.
If you have questions, please contact EGID Member Services at (405) 717-8780 or toll-free (800) 543-6044, ext. 8780. TDD users call (405) 949-2281 or toll-free (866) 447-0436.
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You can verify most of your contract details at https://gateway.sib.ok.gov/ProviderSelfService. You can also verify the locations we have listed for you, your mailing and billing addresses, effective dates, and Tax Identification Numbers. You can review the specialty we have listed for you at various locations and your PIN Number (PIN #). In most cases, your PIN # will appear on your remittance advice and match how claims are processed.
This information is valuable to your practice as it directly affects claim payments. We urge you to periodically check this website to ensure the accuracy of the information we have on file for you. Outdated information can cause claims to be processed as non-Network, paid based on the wrong fee schedule, or denied.
With the Provider Self-Service Tool, you or your employees are able to quickly and easily validate your contract information. This allows you to make certain your claims pay promptly and accurately. If you need more information, please contact Network Management at (405) 717-8790, toll-free (800) 543-6044, or send email inquiries to EGID.NetworkManagement@omes.ok.gov.
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Telehealth Services are excluded under the HealthChoice plans. Any Telehealth Services provided are the member’s responsibility. Prior to services being rendered, providers should make sure patients are aware these are excluded services and any cost will be their responsibility.
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HealthChoice provides our female members coverage for certain contraceptive products and procedures. Additionally, contraceptive counseling services provided by recognized health care providers are also covered. All products are subject to Plan provisions. Following is a list of covered products and services:
The following products are covered under the pharmacy benefits of the HealthChoice health plans. All products require a physician’s prescription:
- Cervical cap
- Oral contraceptives
- Vaginal contraceptive rings
- Transdermal patches
An independent tubal ligation is covered once per lifetime for women ages 18 and older and includes*:
- Facility fees
- Anesthesia fees
- Radiology fees
- Physician fees*
IUD Insertions and Removals
Covered for ages 18 and older and includes:
- IUD or implantable rod – 1 every 5 years
- IUD Insertion – 1 every 5 years
- IUD Removal – 1 every 5 years
Contraceptive injections are covered under the health benefit and require a prescription.
For questions regarding the benefits under the health plan, please contact our Claim Administrator at (405) 416-1800 or toll-free (800) 782-5218.
For questions regarding the benefits under the pharmacy plan, please contact our Pharmacy Benefits Administrator toll-free at (800) 903-8113.
*When a tubal ligation is performed in conjunction with a different surgical procedure, HealthChoice will cover only the surgeon’s fee for the tubal ligation.
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HealthChoice benefits include coverage for medically necessary inpatient behavioral health and substance abuse care, crisis stabilization, emergency care and residential and day treatment for both children and adults. Additionally, outpatient psychiatric services, including pharmacological care, and other outpatient counseling and rehabilitative services can be a covered benefit under the HealthChoice plans.
For more information, please contact our claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
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Beginning Oct. 1, 2013, The Office of Management and Enterprise Services (OMES) Employees Group Insurance Division (EGID) will accept only the revised (version 02/12) 1500 Health Insurance Claim Form.
EGID adopted the NUCC recommended timeline for the transition to the revised 1500 Claim Form (02/12) for all HealthChoice, DOC, and DRS claims.
- June 1, 2013 – Health plans, clearinghouses, and other information support vendors are ready to handle and accept the revised (02/12) 1500 Claim Form.
- June 1 – Oct. 1, 2013 – Providers can use either the current (08/05) or the revised (02/12) 1500 Claim Form. Health plans, clearinghouses, and billing vendors are able to accept and process either version of the form.
- Oct. 1, 2013 – The current (08/05) 1500 Claim Form is discontinued; only the revised (02/12) 1500 Claim Form is to be used. All rebilling of claims will be on the revised (02/12) 1500 Claim Form from this date forward, even though earlier submissions may have been on the current (08/05) 1500 Claim Form.
An instruction manual and change log, along with information on obtaining the revised form is available on the NUCC’s website, www.nucc.org. Early adopters of the revised (02/12) 1500 Claim Form may choose to transition to the revised form earlier based on trading partner agreements. EGID encourages Network Providers to immediately begin the process with their payers and/or clearinghouses to submit the updated form.
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The American Dental Association (ADA) revised their dental claim form effective July 1, 2012. The form was updated primarily to allow dentists to include a diagnosis code when the specific diagnosis may have an impact on the adjudication of the claim. This revision replaces the previous ADA 2006 Dental Claim Form.
Comprehensive ADA dental claim form completion instructions, a sample form, and details of changes included in the new form can be accessed via the website: http://www.ada.org.
HealthChoice, DOC, and DRS will accept both the previous ADA 2006 Dental Claim Form and the revised 2012 ADA Dental Claim Form through Dec. 31, 2013. Beginning Jan. 1, 2014, only the 2012 ADA Dental Claim Form will be accepted.
If you have any questions, please contact Network Management at (405) 717-8790, toll-free (800) 543-6044, or send email inquiries to EGID.NetworkManagement@omes.ok.gov.
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Please note that recent changes to the Office of Management and Enterprise Services (OMES) Employees Group Insurance Division (EGID) resulted in new email addresses. This means the email address for your Network Management Representative has changed. The new email address will be in the format of firstname.lastname@example.org.
General inquiries for HealthChoice Providers should be sent to EGID.NetworkManagement@omes.ok.gov.
For Department of Rehabilitation Services (DRS) and Department of Corrections (DOC) Providers, general inquiries should be sent to EGID.DRSNetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov, respectively.
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HealthChoice and the Department of Corrections (DOC) have reviewed and may have updated their fee schedules as indicated for CPT/HCPCS, Outpatient Facility (OP), Ambulatory Surgery Center (ASC), American Society of Anesthesiologists (ASA), and American Dental Association (ADA) codes effective for charges incurred on or after July 1, 2013, as stated in earlier notifications.
The next quarterly fee schedule review for possible updates will be for charges incurred on or after October 1, 2013, for CPT/HCPCS, OP, ASC, ASA, and ADA codes. A comprehensive fee schedule update for MS-DRG and MS-DRG LTCH codes will also become effective for charges incurred on or after Oct. 1, 2013.
As a reminder, the American Medical Association periodically changes, adds, corrects, and/or deletes procedure codes throughout the year. When these changes occur, HealthChoice and DOC review them as soon as possible and make necessary changes.
Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis when needed. Fee schedule updates are reported in each issue of the Network News newsletter which is distributed quarterly to all Network Providers.
Updates are also posted to the provider websites. We encourage you and your staff to reference the website of your provider network for the most recent fee schedule updates and other important information.
If you want specific codes and allowed charges affected by these updates, or if you have questions, please visit our website at https://gateway.sib.ok.gov/feeschedule or contact Network Management at (405) 717-8790 or toll-free (800) 543-6044. Email inquiries can be sent to EGID.NetworkManagement@omes.ok.gov or EGID.DOCNetworkManagement@omes.ok.gov.
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Do you have an email address? If so, please go to our website and click the link Provider Email Update Form in the Provider Forms section. Complete the Network Provider Newsletter/Correspondence Email Update Form and return to us. (see contact information on page 6)
Once we have your email address, future issues of the Network News will be sent quicker and more efficiently via email.
If we don’t have your email address, you will continue to receive the Network News through the mail.
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Beginning Jan. 1, 2013, HealthChoice non-Medicare female members and dependents are eligible to receive breastfeeding pumps and supplies as follows:
- Breast pumps - One total per lifetime. Billing codes - E0602NU, E0602RR, E0603, E0604
- Supplies - One each per pregnancy. Billing codes- A4281, A4282, A4283, A4284, A4285, A4286
Although considered durable medical equipment (DME), certification by the Health Care Management Unit is not required for these pumps and supplies.
HealthChoice is currently in the process of identifying contracted DME providers of breast pumps and the related supplies in order to increase the availability of these services for its members. Due to the coverage under preventive medicine benefits, we want to identify contracted suppliers who will allow members to walk-in and obtain equipment/supplies.
HealthChoice Network Providers should verify benefits and must submit claims to HealthChoice for the covered equipment/supplies. Members can not be charged up front.
HealthChoice brings you approximately 170,000 members and dependents in the state of Oklahoma.
If you are a contracted DME company that can facilitate this convenience in obtaining breast pumps and related supplies, please forward a response to EGID.NetworkManagement@sib.ok.gov or call (405) 717-8790 or toll-free (800) 543-6044. If you are a physician who is treating a HealthChoice non-Medicare female member or dependent who is pregnant or recently had a baby, please remember that many of these items, though available at no cost to the member, still require a prescription.
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Coverage is Provided Under the Pharmacy Plan for Current and Pre-Medicare Members
Effective July 1, 2013, members, both children and adults, who are not covered by Medicare, are allowed to obtain their routine immunizations and vaccinations at the pharmacy, in accordance with the current Centers for Disease Control and Prevention guidelines. In the past, these were available only under the health plan. The immunizations and/or vaccinations and the administration fees are also covered under the pharmacy program at 100%, if the services are provided by a Network Pharmacy.
Participants are subject to non-Network benefits and can be balanced billed for amounts above the Allowed Charges, if utilizing the services of a non-Network pharmacy.
The existing benefit for immunizations/vaccinations and their administration under the health plan shall remain the same.
Please note that under the health plan:
- Only Network Physicians/Providers/Pharmacists can provide these services.
- Mid-level practitioners such as physician assistants or nurse practitioners practicing at a free-standing ambulatory care clinic located at a pharmacy may or may not be participating providers.
- NON-NETWORK PHARMACISTS ARE NOT RECOGNIZED AND are not covered. Members should verify participating provider status at the time of service.
Immunizations/Vaccinations covered under pharmacy benefit when a Network Pharmacy is used:
||Rabies, Human Diploid
|Rabies, PF Chick-EMB Cell
|Smallpox (Vaccinia) Vaccine
||Tetanus, Diphtheria, Pertussis
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Members and dependents who enroll in the HealthChoice Dental Plan are eligible for orthodontic benefits for charges incurred after the first 12 consecutive months of coverage with HealthChoice Dental.
In cases where a new member or dependent has had previous group dental coverage, any continuing orthodontic services are pro-rated according to HealthChoice Dental Plan rules. This change is effective for all orthodontic services incurred on or after January 1, 2014, including services for the treatment of temporomandibular joint disorder (TMD).
For more information, or if you have questions concerning orthodontic benefits, please contact our dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.
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In an effort to enhance member knowledge and increase participation in 2013, the initiative has been streamlined. The following are changes from prior campaigns:
- The member is no longer required to have metabolic and/or lipid blood panels done to qualify for the $200 incentive, however, these services remain free options to the member.
- The member is no longer required to complete the online health risk assessment (HRA) and update their biometric information. This service also remains a free option for the member to utilize.
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