HealthChoice provider network news Fall 2011 |
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#2568 Network News Fall Edition 2011 Oklahoma State and Education Employees Group Insurance Board A Division of the Office of State Finance New! High and Basic Alternative Plans He lthChoice Provider For additional updates and articles, visit the Network Provider websites. HealthChoice Providers use www.sib.ok.gov or www. healthchoiceok.com. DOC Providers use https://gateway.sib. ok.gov/DOC. DRS Providers use https://gateway.sib.ok.gov/DRS. Each year, tobacco use costs the HealthChoice health plans and their members approximately $52 million. Because these costs impact all health plan premiums, on January 1, 2012, HealthChoice is introducing the High and Basic Alternative Plans for tobacco users. Providers need to be aware that the individual deductibles and out-of-pocket limits for these two plans are each $250 higher than the HealthChoice High and Basic Plans. During Option Period, primary members will be required to complete and submit an Attestation stating they and their covered family members are tobacco-free. Members who do not or cannot complete the tobacco-free Attestation will automatically be enrolled in an Alternative plan. Members and dependents that use tobacco can remain in the High or Basic Plans, which have lower out-of-pocket costs, by providing a letter confirming their enrollment in, or completion of, the HealthChoice tobacco cessation program offered through the Oklahoma Tobacco Help Line at 1-800-Quit-Now. Currently, HealthChoice benefits include $5 copays for certain prescription tobacco cessation medications, free over-the- counter (OTC) nicotine replacement therapy products, and up to five free telephone-coaching sessions. OTC products include lozenges, patches, and gum. Please Note!! Beginning January 1, 2012, HealthChoice will eliminate the $5 copay for prescription products, so the entire quit tobacco program will be free to our members. HealthChoice is committed to helping our members become healthier by removing the cost barriers associated with some quit tobacco programs. It is our hope that our members will take advantage of these benefits and become tobacco free! Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. Each year, HP Administrative Services, LLC (HP), the health and dental claims administrator for HealthChoice, sends 1099 forms to all providers who had claims paid by the Plan. These forms are prepared using identification information submitted by providers on Form W-9. This information must match the information on file with the IRS. When records do not match as required by the IRS, HP must apply 28% backup withholding to future claim payments. Each October, HP sends letters requesting updated W-9 forms from providers whose information is not current. If you are asked to update your Form W-9, please make certain that the following information matches IRS records: • Corporate Name • Address • Tax Identification Number (TIN) Your TIN must match the number listed on your Form SS4. We hope this reminder will help you avoid backup withholding. If you have questions or need further information, please contact HP Administrative Services, LLC. See Network Provider Contact Information on the back page. Avoid Backup Withholding! Introducing Maintenance Network Pharmacies 2 H.E.L.P. 4 Wellness Initiative Continues in 2012 Effective January 1, 2012, for all non-Medicare members, HealthChoice is introducing a new Maintenance Network benefit for long-term, maintenance medications. The Maintenance Network includes both retail and mail-service pharmacies. Currently, CVS, Walmart, and Sam’s Club pharmacies, as well as the Medco pharmacy specializing in mail service, are included in the Maintenance Network. Additionally, recruiting of local, retail pharmacies throughout Oklahoma continues. HealthChoice members will be able to purchase their maintenance medications cheaper through any of the Maintenance Network pharmacies. When long-term, maintenance medications are purchased through any of the Maintenance Network pharmacies, a 90-day supply of medication will be available for one copay; however, when maintenance medications are purchased at a pharmacy other than a Maintenance Network pharmacy, only a 30-day supply of medication will be available for one copay. If retail pharmacies in your area do not become Maintenance Network pharmacies, members are assured access to a Maintenance Network pharmacy because Medco’s mail service pharmacy is available to all members. It’s also important to note that members’ benefits for short-term medications will not be affected, regardless of where they are purchased. When prescribing for HealthChoice members, prescriptions for long-term, maintenance medications should be written for a 90-day supply. When appropriate, providers should indicate refills are available for up to one year. We anticipate that our providers will receive increased calls from HealthChoice members requesting new prescriptions for maintenance medications so they can take advantage of the cost savings available through Maintenance Network pharmacies. To view a summary list of long-term, maintenance medications, visit www.healthchoiceok.com or www.sib.ok.gov or contact Medco toll-free at 1-800-903-8113. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov. See Network Provider Contact Information on the back page. HealthChoice will continue its H.E.L.P. 4 (Help Check) wellness initiative in 2012. H.E.L.P. 4 combines an online, interactive health risk assessment with the results of certain free preventive services to provide our members with personalized health information as well as the steps they need to take to improve their health. Primary health plan members who complete the requirements of the H.E.L.P. 4 initiative receive a $100 incentive payment from HealthChoice. The program is available to all primary non-Medicare plan members age 20 and older. HealthChoice Provider Relations is meeting with our Network Providers to help familiarize them with the wellness initiative and free preventive services offered by HealthChoice. These meetings provide specific details about the free preventive services and the appropriate codes to bill for 100% reimbursement of Allowed Charges. Additional information regarding the HealthChoice provider website, ClaimLink, and other upcoming initiatives will also be discussed. We hope our Network Providers will take advantage of this opportunity and schedule one of these informative meetings. The meetings are conducted by Teresa South, Director of Provider Relations, and Cassie Waters, Director of Plan Benefits and Health Promotion. To schedule a meeting, contact Teresa South at 1-405-717-8627 or toll-free 1-800- 543-6044, ext. 8627. You can also email Teresa at tsouth@sib.ok.gov. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. CPT Code Modifier 33, Preventive Service Updated! Effective for charges incurred on or after January 1, 2012, HealthChoice and Department of Corrections (DOC) Network Providers will be reimbursed 100% of Allowed Charges for the following evaluation and management codes when they are billed using Modifier 33 to identify them as preventive services: CPT Codes Description 99201 Office or other outpatient visit 99202 Office or other outpatient visit 99203 Office or other outpatient visit 99204 Office or other outpatient visit 99205 Office or other outpatient visit 99211 Office or other outpatient visit 99212 Office or other outpatient visit 99213 Office or other outpatient visit 99214 Office or other outpatient visit 99215 Office or other outpatient visit Be aware that CPT Code Modifier 33 applies only to services provided to pre-Medicare patients. Additionally, Modifier 33 should not be used for services that are already identified as preventive. Questions should be directed to HP Administrative Services, LLC at 1-405-416-1800 or toll-free 1-800-782- 5218. 3 New Benefits for Preventive Services Effective January 1, 2012, HealthChoice will adopt new benefits for preventive services. This means certain preventive procedures will be covered at 100% of Allowed Charges for our members who meet the clinical criteria when using a HealthChoice Network Provider.* Following is a list of some of the services that will be free to eligible members: ♦♦ Blood pressure, diabetes, and cholesterol tests ♦♦ Breast, cervical, prostate, and colorectal cancer screenings ♦♦ Osteoporosis screening ♦♦ Counseling from health care providers on topics including quitting tobacco, losing weight, eating healthy, treating depression, and reducing alcohol use ♦♦ Prescription tobacco cessation products ♦♦ Vaccines for children and adults ♦♦ Flu and pneumonia shots ♦♦ Screening for obesity and counseling by a doctor and other health professionals to promote sustained weight loss, including dietary counseling from a doctor ♦♦ Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria ♦♦ Special, pregnancy-tailored counseling from a doctor to help pregnant women quit smoking and avoid alcohol use ♦♦ Counseling to support breast-feeding and help nursing mothers Additional information on this subject is available on the provider website at www.sib.ok.gov/providers. *When using a non-Network provider, these services will be covered according to Plan benefits. 4 Providers Should Test Claims for HIPAA 5010 Compliance Beginning January 1, 2012, all health/dental plans, claims clearinghouses, and health/ dental providers must use new standards for electronic healthcare transactions. These new standards, known as HIPAA 5010, will impact claims, claims status requests, and eligibility requests and responses. The purpose of these new standards is to provide precise instructions and reduce unnecessary information; however, the new standards also require that certain information be recorded differently. As an example, under HIPAA 5010 guidelines, the billing address, Loop 2010AA, can no longer be reported as a post office box or lockbox address. OSEEGIB previously requested that all Network Providers who bill on an 837P or 837D submit the “Pay to or Remit Address” in loop 2010AA. Under the new HIPAA 5010 guidelines, providers who bill using an 837P or 837D will need to submit their “Pay to or Remit Address” in loop 2010AB. Network Providers will continue to receive Remittance Advices at their contracted “billing/ remit/pay to address”; however, providers with multiple “billing/ pay to” addresses associated with the same TIN/NPI could have claim documents sent to the address associated with the first Network contract identified for the provider. Providers that want to receive claim payments/documents at multiple “billing/remit/pay to” addresses must submit a separate TIN for each separate “billing/ remit/pay to” address. Emdeon, the claims clearing house for HP Administrative Services, LLC, began accepting test claims for 5010 compliance in the third week of October, 2011. Providers are strongly urged to test claims for HIPAA 5010 compliance and may visit the Emdeon website at http://www.emdeon.com/5010/ for further information. HP Administrative Services, LLC is not accepting claims for testing compliance from providers as they are testing directly with Emdeon. As January 1, 2012 approaches, OSEEGIB would like to remind providers that all electronic transactions must conform to these new standards. Claims that are not in compliance will be rejected or denied. In order to make this change to HIPAA 5010 standards go as smoothly as possible, we strongly recommend each provider work with their claims clearinghouse and software vendors to ensure that their systems will be in compliance on January 1, 2012. In response to requests from our Network Providers, HealthChoice and DOC have modified their online fee schedule search to include historical information for each procedure code. Once you’ve completed a search, click View History to view the historical information. Please send email inquiries to oseegibproviderrelations@ sib.ok.gov or contact a Provider Relations Specialist. See Network Provider Contact Information on the back page. Fee Schedule Search Modified to Include History Correction! Fee Schedule for Services When the Patient is Not Present CPT Code 99308 (subsequent nursing facility care; per day for evaluation and management of patient) was listed in error in a recent article about this Plan’s coverage for services when the patient is not present. This article appeared in the summer edition of our provider newsletter, Network News, and also on our website. Please excuse our mistake as CPT Code 99308 is a covered service. For a list of CPT Codes that are not covered when the patient is not present, go to the HealthChoice website at www.sib.ok.gov/ providers or the DOC website at https://gateway.sib.ok.gov/DOC and click on the link contained in the corrected article. CPT Category II Codes (F Codes) Effective for charges incurred on or after January 1, 2012, HealthChoice and DOC will recognize Category II Codes (F Codes) only for reporting purposes. Procedures and/or services reported using these codes are not covered and are not eligible for reimbursement. If you have questions regarding this issue, contact HealthChoice or DOC Provider Relations. See Network Provider Contact Information on the back page. Email inquiries can be sent to oseegibproviderrelations@sib. ok.gov. Mental Health/Substance Use Disorder Limits Removed 5 HealthChoice is removing the limits on the duration of treatment for inpatient and outpatient mental health and substance use disorder. The chart below compares the Plan’s current benefits to the benefits that will be effective January 1, 2012: Mental Health and Substance Use Disorder Treatment 2011 Benefits 2012 Benefits Inpatient Treatment Including day treatment and residential treatment Limited to 30 days per calendar year*; certification is required Certification is required Outpatient Treatment Limited to 26 visits per calendar year*; certification is required after 15 visits Certification is required after 15 visits Although the limits to the duration of treatment are being removed, providers will still need to follow HealthChoice certification procedures as described below: Inpatient treatment must be certified within 3 working days of a scheduled hospital admission, or within 1 working day following an emergency admission. To request certification for an inpatient admission, contact APS Healthcare toll-free at 1-800-848-8121. Outpatient treatment must be certified for medical necessity when visits exceed 15 per calendar year. To request certification for outpatient treatment, contact the HealthChoice Health Care Management Division at 1-405-717-8879 or toll-free 1-800-543-6044, ext. 8879. For additional information regarding the certification process, reference the Utilization Review section of the HealthChoice Network Provider Manual which is available on the HealthChoice provider website at www.sib. ok.gov/providers, or contact Provider Relations. See Network Provider Contact Information on the back page. *Exceptions to the current 30-day limit are made for the diagnoses of schizophrenia, bipolar disorder/manic-depressive illnesses, major depressive disorder, panic disorder, obsessive-compulsive disorder, and schizo-affective disorder. Sclerotherapy Not a Covered Benefit Beginning with charges incurred on or after February 1, 2012, the HealthChoice fee schedule will show sclerotherapy as NC (Not Covered). Sclerotherapy is considered cosmetic and is not covered by HealthChoice. The following CPT Codes will show NC status: CPT Code Descriptions Allowables 36468 Single or multiple injections of sclerosing solutions; spider veins (telangiectasia); limb or trunk NC 36470 Injection of sclerosing solution; single vein NC 36471 Injection of sclerosing solution; multiple veins, same leg NC Saphenous Vein Ablation-Laser and Radiofrequency will continue to be covered procedures; however, certification is required. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. New Coverage for Non-Network Emergency Room Services 6 Effective for charges incurred on or after January 1, 2012, HealthChoice will reimburse all emergency room services based on Network benefits. The Network benefits for HealthChoice Network Facilities will apply regardless of whether or not a facility is contracted with HealthChoice. All ancillary services provided in an emergency room that occur on the same date of service will also be reimbursed according to Network benefits. To be reimbursed at the Network rate, non-Network facilities must submit claims using Place of Service Code 23. Facilities need to be aware that the $100 emergency room deductible will continue to apply to emergency room services when the patient is not admitted to the hospital. Following are the Revenue Codes that will be affected by the new reimbursement criteria: Revenue Codes Descriptions 450 Emergency Room 451 Emergency Room: ER/Emergency Medical Treatment and Active Labor Act (EMTALA) 452 Emergency Room: ER/Beyond EMTALA 456 Emergency Room: Urgent Care 459 Emergency Room: Other Emergency Room Note: All codes are subject to change. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. FaxBack Feature for Providers HealthChoice providers now have the ability to immediately receive current plan information as well as member eligibility, deductible, and out-of-pocket limit information by fax. This new option is available through FaxBack. FaxBack allows you to enter your fax number and request information be faxed directly to your office. FaxBack documents include: yy A Summary of Benefits for the member’s plan yy Accumulators for the member’s plan yy Certification requirements FaxBack is available 24 hours a day, 7 days a week. To access FaxBack, contact HP customer service at 1-405-416-1800 or toll-free 1-800-782-5218 and follow the prompts of the automated system. Please have the following information available before placing your call: yy Your 10-digit NPI number or 9-digit social security number yy Your fax number yy Member’s identification number yy Member’s date of birth We hope our providers will find FaxBack an easy to use, convenient method for obtaining HealthChoice member information. Fee Schedule Updates HealthChoice and the Department of Corrections (DOC) have updated MS-DRG, MS-DRG LTCH, and outpatient fee schedules. Changes are effective for charges incurred on or after October 1, 2011. The CPT/HCPCS, ASC, ASA, and ADA fee schedules for HealthChoice and DOC have been updated and changes will be effective for charges incurred on or after January 1, 2012. Be aware that HealthChoice and DOC update the CPT/HCPCS, outpatient hospital, ASC, ASA, and ADA fee schedules quarterly. 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. Fee schedule updates are reported in each issue of this newsletter, which is distributed quarterly to Network Providers. Updates are also posted to the provider websites. We encourage you and your staff to reference the website for each Network for the most recent fee schedule updates and other important information. If you have questions, you are welcome to contact the Provider Relations Division. See Network Provider Contact Information on the back page. Fee Schedule Changes for Sealants and Preventive Resin Restorations Effective for charges incurred on or after April 1, 2012, the Allowed Charges for sealant – one tooth (D1351) and preventive resin restoration (D1352) will be revised as indicated below: CDT Code Description Allowable Charge D1351 Sealant – per tooth $31.00 D1352 Preventive resin restoration in a moderate to high caries risk patient-permanent tooth $46.00 Additionally, coverage for preventive resin restoration will be restricted to only permanent teeth; however, there will be no restrictions regarding the age of the patient. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. Providers May Want to Join DOC Network Due to DOC Fee Schedule Mandate Senate Bill 180 was recently signed into law by Governor Fallin. The bill mandates a change to the fee schedule for non-Network providers who provide services to Department of Corrections (DOC) inmates. Effective for charges incurred on or after November 1, 2011, DOC non-Network providers will be subject to the current Medicaid fee schedule. The DOC reimbursement rates for Network Providers are greater than the current Oklahoma Medicaid fee schedule. If you have questions about the DOC fee schedule and how to become a Network Provider for DOC, please contact the Provider Relations Division. See Network Provider Contact Information on the back page or email DOCProviderRelations@ sib.ok.gov. Post Treatment, Breast Symmetry Surgery Effective for charges incurred on or after January 1, 2012, HealthChoice will cover post treatment, breast symmetry surgery following breast-conserving surgery (lumpectomy) when the lumpectomy is medically necessary. All surgeries for post treatment, breast symmetry surgery must be certified through APS Healthcare. Photographs must be submitted for review. If you have questions about this new coverage, please contact the Provider Relations Division at 1-405-717-8790 or toll-free 1-800- 543-6044. To certify a procedure, contact APS Healthcare toll-free at 1-800- 848-8121. 7 Home Health Care Services Effective for charges incurred on or after January 1, 2012, the following HCPCS procedure codes will not be covered when services are provided in an office or outpatient setting: HCPCS Code Description G0151 Physical therapist in home health or hospice setting; each 15 minutes G0152 Occupational therapist in home health or hospice setting; each 15 minutes G0153 Speech/language pathologist in home health or hospice setting; each 15 minutes G0154 Skilled nurse in home health or hospice setting; each 15 minutes G0155 Clinical social worker in home health or hospice setting; each 15 minutes G0156 Home health or hospice aide in home health or hospice setting; each 15 minutes S0274 Nurse practitioner visit at member’s house, outside of a capitation arrangement One CPT/HCPCS code will be allowed per home health care provider per day for the following codes when services are provided in an office or outpatient setting: CPT/HCPCS Code Description 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring 99501 Home visit for postnatal assessment and follow-up care 99502 Home visit for newborn care and assessment 99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation) 99504 Home visit for mechanical ventilation care 99505 Home visit for stoma care and maintenance including colostomy and cystostomy 99506 Home visit for intramuscular injections 99507 Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral) 99509 Home visit for assistance with activities of daily living and personal care 99510 Home visit for individual, family, or marriage counseling 99511 Home visit for fecal impaction management and enema administration 99512 Home visit for hemodialysis 99600 Unlisted home visit service or procedure 99601 Home infusion/specialty drug administration, per visit (up to 2 hours) S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PCC), nursing services only (no supplies or catheter included) S5523 Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included) S9097 Home visit for wound care S9098 Home visit, phototherapy services (e.g. Bil-lite), including equipment rental, nursing services, blood draw, supplies, and other services, per diem S9122 Home health aide or certified nurse assistant, providing care in the home, per hour S9123 Nursing care, in the home, by registered nurse, per hour S9124 Nursing care, in the home, by licensed practical nurse, per hour continued on next page 8 9 Changes to the Certification List for 2012 For charges incurred on or after January 1, 2012, HealthChoice is making some changes to its current list of procedures and/or services that require certification. The following will be added to the list of services requiring certification: yy Spinal Cord Stimulator Placement Surgery (CPT Codes 63650, 63655, 63661, 63662, 63663, 63664, 63685 and 63688, and HCPCS Codes L8682, L8685, L8686, L8687 and L8688) The following will be removed from the list of services requiring certification: yy PET Scans for Tumor Imaging (CPT Codes 78811, 78812, 78813, 78814, 78815 and 78816) yy Speech Therapy for plan members and their covered dependents 18 years of age or older (CPT Codes 92507 and 92508, and HCPCS Codes S9128 and S9152) yy Xolair Injection, omalizumab 5mg (J Code J2357) Note: All CPT/HCPCS codes are subject to change. Please direct questions about the certification process to the HealthChoice Provider Relations Division at 1-405-717-8790 or toll-free 1-800-543-6044. Questions can also be sent to Provider Relations by email to oseegibproviderrelations@sib.ok.gov. Department of Rehabilitation Services Recruiting Providers The Department of Rehabilitation Services (DRS) is in the process of recruiting providers for its Network. DRS is the state agency that provides vocational rehabilitation to disabled individuals to help them become more independent, productive members of the Oklahoma workforce. If you are interested in learning more about DRS, please visit the DRS Network Provider website at https://gateway.sib.ok.gov/DRS. To access the DRS fee schedule, simply click Fee Schedule in the top menu bar. If you are interested in joining the DRS Network, contracts are available under the Contracts tab in the top menu bar. Please send email inquiries to DRSProviderRelations@sib.ok.gov or contact DRS Provider Relations at 1-405-717-8921 or toll-free 1-888-835-6919. Benlysta® Treatment Requires Certification Benlysta® (belimumab) is a new intravenous medication used to treat lupus in adults. HealthChoice requires providers to obtain certification through its Health Care Management Division before beginning treatment with this medication. To certify treatment with this medication, providers must complete and submit a Benlysta® Request Form for approval. This form is available on the provider website at www.sib.ok.gov/providers. S9125 Respite care, in the home, per diem S9126 Hospice care, in the home, per diem S9127 Social work visit, in the home, per diem S9128 Speech therapy, in the home, per diem S9129 Occupational therapy, in the home, per diem S9131 Physical therapy, in the home, per diem Units billed will be allowed for the following code when services are provided in an office or outpatient setting: CPT Code Description 99602 Home infusion/specialty drug administration, per visit (up to 2 hours) each additional hour Note: All CPT/HCPCS codes are subject to change. Certification for home health care services is required through the HealthChoice Health Care Management Division. See Network Provider Contact Information on the back page. If you have questions regarding this issue, contact HealthChoice Provider Relations. See Network Provider Contact Information on the back page. continued from previous page 10 HealthChoice, DOC, DRS to Adopt Electronic Claims Payments 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). Effective July 1, 2012, any provider who has not authorized EFT for their contract will be at risk for delayed claims payments. EFT is fast and secure, and reimbursements are deposited directly to the bank account you designate. You will continue to receive paper remittance advices (RAs) to assist with accounts reconciliation. Practice groups that use the same bank account for multiple providers under the same TIN need to submit only one form to OSEEGIB along with a list of their affiliated providers. The HealthChoice, DOC, and DRS electronic funds transfer and online RA programs offer these advantages: yy Claim payments are automatically deposited yy RAs can be searched online through ClaimLink yy Access to current and historical RAs through ClaimLink yy Less paper handling All you have to do is complete the form and return it to OSEEGIB as indicated. We will take care of the rest. Enhance your cash flow management and sign up today for EFT! The EFT Authorization Form is available from the following websites: yy http://www.ok.gov/sib/ Providers/Provider_Forms/ index.html yy https://gateway.sib.ok.gov/ DOC/Forms.aspx yy https://gateway.sib.ok.gov/ drs/Forms.aspx You’ll need to allow two to four weeks for your registration to be processed, so don’t wait until the last minute to sign up! If you have any questions, please contact Provider Relations at 1-405-717-8790 or toll-free 1-800- 543-6044, or send email inquiries to oseegibproviderrelations@sib. ok.gov. New! Provider Applications Can Be Completed Online Providers now have the ability to complete and submit the HealthChoice, DOC, and DRS Network Provider Applications online. In order to submit an application online, you must have the ability to email an electronic signature to HealthChoice Provider Relations. If you don’t have an electronic signature, the Health Insurance Prospective Payment System HealthChoice will accept Health Insurance Prospective Payment System (HIPPS) Codes effective February 1, 2012. These HIPPS Codes will be recorded for reporting purposes only. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. application can be completed, scanned, and then emailed to OSEEGIBproviderrelations@sib. ok.gov. If this is not an option for you, complete the application and mail it to: HealthChoice Provider Relations Division 3545 NW 58 Street, Suite 110 Oklahoma City, OK 73112 Or fax your application to 1-405-717-8977. If you have questions or need more information, please contact HealthChoice Provider Relations. See Network Provider Contact Information on the back page. Timely Claims-Filing Deadline Waived for Coordination of Benefits For charges incurred on or after February 1, 2012, HealthChoice will waive the timely claims-filing deadline as it applies to Coordination of Benefits for providers who file standard HIPAA 837 claims. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact HP Administrative Services, LLC at 1-405-416-1800 or toll-free 1-800-782-5218. 11 Medications Now Available in Generic Form New generic medications are now available for the brand-name medications listed below. If you prescribe any of these brand-name medications to HealthChoice members, please note that the generic medication saves them money at the pharmacy. This applies to all HealthChoice members, including all members of the HealthChoice Medicare Supplement Plans With and Without Part D. Brand-Name Medication Generic Medication Treatment Launch Date Alsuma sumatriptan injection Migraine/cluster headaches Aug 2011 Amrix cyclobenzaprine HCL extended-release capsules Muscle relaxant May 2011 Aromasin exemestane Breast cancer Apr 2011 Carbatrol carbamazepine Epilepsy or nerve pain May 2011 Concerta methylphenidate hydrochloride extended release tablets ADHD May 2011 Elestat Ophthalmic epinastine HCL ophthalmic solution Allergic conjunctivitis May 2011 Femara letrozole 2.5mg tablets Breast cancer Apr 2011 Femcon Fe norethindrone and ethinyl estradiol Birth control Apr 2011 FemHrt 1-5 ethinyl estradiol and norethindrone Hormone replacement Feb 2011 Furadantin Suspension nitrofurantoin Antibiotic - urinary tract infection June 2011 Levaquin levofloxacin Antibiotic June 2011 Lotrel 5/40 & 10/40mg amlodipine besylate/benazepril HCL Hypertension Jan 2011 Lybrel levonorgestrel and ethinyl estradiol Birth control June 2011 Nasacort AQ triamcinolone acetonide Nasal allergy symptoms June 2011 Nitrolingual Pump Spray glyceryl trinitrate Heart (blood flow) Mar 2011 Prenate Essential PNV with CA#68/Iron Pregnancy – nutritional supplement June 2011 PreNexa PNV66/iron fumarate Pregnancy – nutritional supplement June 2011 Rythmol SR propafenone SR 225mg, 325mg, 425mg capsules Abnormal heart rhythm Jan 2011 Seasonique ethinyl estradiol & levonorgestrel Birth control Aug 2011 Sular 8.5m 17, 25.5 & 34mg nisoldipine High blood pressure Jan 2011 Uroxatral alfuzosin hydrocholoride Benign prostatic hyperplasia July 2011 Vfend voriconazole 50 & 20mg Serious fungal infections Feb 2011 Xalatan latanoprost ophthalmic solution Glaucoma Mar 2011 This publication is printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance as authorized by 74 O.S. , Section 1301. 4,000 copies have been printed at a cost of $0.35 each. Copies have been deposited with Publications Clearinghouse of the Oklahoma Department of Libraries. He lthChoice Provider Network News 3545 NW 58 Street, Suite 110 Oklahoma City, OK 73112 www.sib.ok.gov www.healthchoiceok.com Presorted First-Class U. S. Postage PAID Permit #1067 Okla. City, OK Network Provider Contact Information DOC Provider Relations https://gateway.sib.ok.gov/DOC OKC Area 1-405-717-8750 Toll-free 1-866-573-8462 DOC Health and Dental Claims HP Administrative Services, LLC P. O. Box 268928 Oklahoma City, OK 73126-8928 Toll-free 1-800-262-7683 DRS Provider Relations https://gateway.sib.ok.gov/DRS OKC Area 1-405-717-8921 Toll-free 1-888-835-6919 DRS Health and Dental Claims HP Administrative Services, LLC P.O. Box 25069 Oklahoma City, OK 73125-0069 Toll-free 1-800-944-7938 HealthChoice Providers www.sib.ok.gov www.healthchoiceok.com Health and Dental Claims HP Administrative Services, LLC P.O. Box 24870 Oklahoma 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 Medco Health Solutions Pharmacy 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 1-405-416-1755 HealthChoice Health Care Management Division OKC Area 1-405-717-8879 Toll-free 1-800-543-6044 Ext. 8879 HealthChoice Provider Relations OKC Area 1-405-717-8790 Toll-free 1-800-543-6044
Object Description
Okla State Agency | Employees Group Insurance Board, Oklahoma State and Education (OSEEGIB) |
Okla Agency Code | '516' |
Title | Network news |
Alternative title | HealthChoice provider network news |
Authors | Oklahoma State and Education Employees Group Insurance Board. |
Publisher | Oklahoma State and Education Employees Group Insurance Board |
Publication Date | 2008; 2009; 2010; 2011 |
Publication type | Newsletter |
Serial holdings | Electronic holdings: 2008-2011 |
Subject | Insurance, Government employees' health--Oklahoma--Periodicals. |
Notes | issues through 2011 |
OkDocs Class# | E3610.6 N476n |
For all issues click | E3610.6 N476n |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Downloaded from agency website: http://www.sib.state.ok.us/providers/NetworkNews.asp |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders. |
Language | English |
Month/year uploaded | October 2009 |
Date created | 2014-10-08 |
Date modified | 2014-10-08 |
OCLC number | 829700995 |
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Title | HealthChoice provider network news Fall 2011 |
OkDocs Class# | E3610.6 N476n Fall 2011 |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Downloaded from agency website: http://www.ok.gov/sib/documents/NN%20Fall%202011.pdf |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U. S. copyright law. Other usage requires permission of copyright holders |
Language | English |
Full text | #2568 Network News Fall Edition 2011 Oklahoma State and Education Employees Group Insurance Board A Division of the Office of State Finance New! High and Basic Alternative Plans He lthChoice Provider For additional updates and articles, visit the Network Provider websites. HealthChoice Providers use www.sib.ok.gov or www. healthchoiceok.com. DOC Providers use https://gateway.sib. ok.gov/DOC. DRS Providers use https://gateway.sib.ok.gov/DRS. Each year, tobacco use costs the HealthChoice health plans and their members approximately $52 million. Because these costs impact all health plan premiums, on January 1, 2012, HealthChoice is introducing the High and Basic Alternative Plans for tobacco users. Providers need to be aware that the individual deductibles and out-of-pocket limits for these two plans are each $250 higher than the HealthChoice High and Basic Plans. During Option Period, primary members will be required to complete and submit an Attestation stating they and their covered family members are tobacco-free. Members who do not or cannot complete the tobacco-free Attestation will automatically be enrolled in an Alternative plan. Members and dependents that use tobacco can remain in the High or Basic Plans, which have lower out-of-pocket costs, by providing a letter confirming their enrollment in, or completion of, the HealthChoice tobacco cessation program offered through the Oklahoma Tobacco Help Line at 1-800-Quit-Now. Currently, HealthChoice benefits include $5 copays for certain prescription tobacco cessation medications, free over-the- counter (OTC) nicotine replacement therapy products, and up to five free telephone-coaching sessions. OTC products include lozenges, patches, and gum. Please Note!! Beginning January 1, 2012, HealthChoice will eliminate the $5 copay for prescription products, so the entire quit tobacco program will be free to our members. HealthChoice is committed to helping our members become healthier by removing the cost barriers associated with some quit tobacco programs. It is our hope that our members will take advantage of these benefits and become tobacco free! Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. Each year, HP Administrative Services, LLC (HP), the health and dental claims administrator for HealthChoice, sends 1099 forms to all providers who had claims paid by the Plan. These forms are prepared using identification information submitted by providers on Form W-9. This information must match the information on file with the IRS. When records do not match as required by the IRS, HP must apply 28% backup withholding to future claim payments. Each October, HP sends letters requesting updated W-9 forms from providers whose information is not current. If you are asked to update your Form W-9, please make certain that the following information matches IRS records: • Corporate Name • Address • Tax Identification Number (TIN) Your TIN must match the number listed on your Form SS4. We hope this reminder will help you avoid backup withholding. If you have questions or need further information, please contact HP Administrative Services, LLC. See Network Provider Contact Information on the back page. Avoid Backup Withholding! Introducing Maintenance Network Pharmacies 2 H.E.L.P. 4 Wellness Initiative Continues in 2012 Effective January 1, 2012, for all non-Medicare members, HealthChoice is introducing a new Maintenance Network benefit for long-term, maintenance medications. The Maintenance Network includes both retail and mail-service pharmacies. Currently, CVS, Walmart, and Sam’s Club pharmacies, as well as the Medco pharmacy specializing in mail service, are included in the Maintenance Network. Additionally, recruiting of local, retail pharmacies throughout Oklahoma continues. HealthChoice members will be able to purchase their maintenance medications cheaper through any of the Maintenance Network pharmacies. When long-term, maintenance medications are purchased through any of the Maintenance Network pharmacies, a 90-day supply of medication will be available for one copay; however, when maintenance medications are purchased at a pharmacy other than a Maintenance Network pharmacy, only a 30-day supply of medication will be available for one copay. If retail pharmacies in your area do not become Maintenance Network pharmacies, members are assured access to a Maintenance Network pharmacy because Medco’s mail service pharmacy is available to all members. It’s also important to note that members’ benefits for short-term medications will not be affected, regardless of where they are purchased. When prescribing for HealthChoice members, prescriptions for long-term, maintenance medications should be written for a 90-day supply. When appropriate, providers should indicate refills are available for up to one year. We anticipate that our providers will receive increased calls from HealthChoice members requesting new prescriptions for maintenance medications so they can take advantage of the cost savings available through Maintenance Network pharmacies. To view a summary list of long-term, maintenance medications, visit www.healthchoiceok.com or www.sib.ok.gov or contact Medco toll-free at 1-800-903-8113. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov. See Network Provider Contact Information on the back page. HealthChoice will continue its H.E.L.P. 4 (Help Check) wellness initiative in 2012. H.E.L.P. 4 combines an online, interactive health risk assessment with the results of certain free preventive services to provide our members with personalized health information as well as the steps they need to take to improve their health. Primary health plan members who complete the requirements of the H.E.L.P. 4 initiative receive a $100 incentive payment from HealthChoice. The program is available to all primary non-Medicare plan members age 20 and older. HealthChoice Provider Relations is meeting with our Network Providers to help familiarize them with the wellness initiative and free preventive services offered by HealthChoice. These meetings provide specific details about the free preventive services and the appropriate codes to bill for 100% reimbursement of Allowed Charges. Additional information regarding the HealthChoice provider website, ClaimLink, and other upcoming initiatives will also be discussed. We hope our Network Providers will take advantage of this opportunity and schedule one of these informative meetings. The meetings are conducted by Teresa South, Director of Provider Relations, and Cassie Waters, Director of Plan Benefits and Health Promotion. To schedule a meeting, contact Teresa South at 1-405-717-8627 or toll-free 1-800- 543-6044, ext. 8627. You can also email Teresa at tsouth@sib.ok.gov. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. CPT Code Modifier 33, Preventive Service Updated! Effective for charges incurred on or after January 1, 2012, HealthChoice and Department of Corrections (DOC) Network Providers will be reimbursed 100% of Allowed Charges for the following evaluation and management codes when they are billed using Modifier 33 to identify them as preventive services: CPT Codes Description 99201 Office or other outpatient visit 99202 Office or other outpatient visit 99203 Office or other outpatient visit 99204 Office or other outpatient visit 99205 Office or other outpatient visit 99211 Office or other outpatient visit 99212 Office or other outpatient visit 99213 Office or other outpatient visit 99214 Office or other outpatient visit 99215 Office or other outpatient visit Be aware that CPT Code Modifier 33 applies only to services provided to pre-Medicare patients. Additionally, Modifier 33 should not be used for services that are already identified as preventive. Questions should be directed to HP Administrative Services, LLC at 1-405-416-1800 or toll-free 1-800-782- 5218. 3 New Benefits for Preventive Services Effective January 1, 2012, HealthChoice will adopt new benefits for preventive services. This means certain preventive procedures will be covered at 100% of Allowed Charges for our members who meet the clinical criteria when using a HealthChoice Network Provider.* Following is a list of some of the services that will be free to eligible members: ♦♦ Blood pressure, diabetes, and cholesterol tests ♦♦ Breast, cervical, prostate, and colorectal cancer screenings ♦♦ Osteoporosis screening ♦♦ Counseling from health care providers on topics including quitting tobacco, losing weight, eating healthy, treating depression, and reducing alcohol use ♦♦ Prescription tobacco cessation products ♦♦ Vaccines for children and adults ♦♦ Flu and pneumonia shots ♦♦ Screening for obesity and counseling by a doctor and other health professionals to promote sustained weight loss, including dietary counseling from a doctor ♦♦ Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria ♦♦ Special, pregnancy-tailored counseling from a doctor to help pregnant women quit smoking and avoid alcohol use ♦♦ Counseling to support breast-feeding and help nursing mothers Additional information on this subject is available on the provider website at www.sib.ok.gov/providers. *When using a non-Network provider, these services will be covered according to Plan benefits. 4 Providers Should Test Claims for HIPAA 5010 Compliance Beginning January 1, 2012, all health/dental plans, claims clearinghouses, and health/ dental providers must use new standards for electronic healthcare transactions. These new standards, known as HIPAA 5010, will impact claims, claims status requests, and eligibility requests and responses. The purpose of these new standards is to provide precise instructions and reduce unnecessary information; however, the new standards also require that certain information be recorded differently. As an example, under HIPAA 5010 guidelines, the billing address, Loop 2010AA, can no longer be reported as a post office box or lockbox address. OSEEGIB previously requested that all Network Providers who bill on an 837P or 837D submit the “Pay to or Remit Address” in loop 2010AA. Under the new HIPAA 5010 guidelines, providers who bill using an 837P or 837D will need to submit their “Pay to or Remit Address” in loop 2010AB. Network Providers will continue to receive Remittance Advices at their contracted “billing/ remit/pay to address”; however, providers with multiple “billing/ pay to” addresses associated with the same TIN/NPI could have claim documents sent to the address associated with the first Network contract identified for the provider. Providers that want to receive claim payments/documents at multiple “billing/remit/pay to” addresses must submit a separate TIN for each separate “billing/ remit/pay to” address. Emdeon, the claims clearing house for HP Administrative Services, LLC, began accepting test claims for 5010 compliance in the third week of October, 2011. Providers are strongly urged to test claims for HIPAA 5010 compliance and may visit the Emdeon website at http://www.emdeon.com/5010/ for further information. HP Administrative Services, LLC is not accepting claims for testing compliance from providers as they are testing directly with Emdeon. As January 1, 2012 approaches, OSEEGIB would like to remind providers that all electronic transactions must conform to these new standards. Claims that are not in compliance will be rejected or denied. In order to make this change to HIPAA 5010 standards go as smoothly as possible, we strongly recommend each provider work with their claims clearinghouse and software vendors to ensure that their systems will be in compliance on January 1, 2012. In response to requests from our Network Providers, HealthChoice and DOC have modified their online fee schedule search to include historical information for each procedure code. Once you’ve completed a search, click View History to view the historical information. Please send email inquiries to oseegibproviderrelations@ sib.ok.gov or contact a Provider Relations Specialist. See Network Provider Contact Information on the back page. Fee Schedule Search Modified to Include History Correction! Fee Schedule for Services When the Patient is Not Present CPT Code 99308 (subsequent nursing facility care; per day for evaluation and management of patient) was listed in error in a recent article about this Plan’s coverage for services when the patient is not present. This article appeared in the summer edition of our provider newsletter, Network News, and also on our website. Please excuse our mistake as CPT Code 99308 is a covered service. For a list of CPT Codes that are not covered when the patient is not present, go to the HealthChoice website at www.sib.ok.gov/ providers or the DOC website at https://gateway.sib.ok.gov/DOC and click on the link contained in the corrected article. CPT Category II Codes (F Codes) Effective for charges incurred on or after January 1, 2012, HealthChoice and DOC will recognize Category II Codes (F Codes) only for reporting purposes. Procedures and/or services reported using these codes are not covered and are not eligible for reimbursement. If you have questions regarding this issue, contact HealthChoice or DOC Provider Relations. See Network Provider Contact Information on the back page. Email inquiries can be sent to oseegibproviderrelations@sib. ok.gov. Mental Health/Substance Use Disorder Limits Removed 5 HealthChoice is removing the limits on the duration of treatment for inpatient and outpatient mental health and substance use disorder. The chart below compares the Plan’s current benefits to the benefits that will be effective January 1, 2012: Mental Health and Substance Use Disorder Treatment 2011 Benefits 2012 Benefits Inpatient Treatment Including day treatment and residential treatment Limited to 30 days per calendar year*; certification is required Certification is required Outpatient Treatment Limited to 26 visits per calendar year*; certification is required after 15 visits Certification is required after 15 visits Although the limits to the duration of treatment are being removed, providers will still need to follow HealthChoice certification procedures as described below: Inpatient treatment must be certified within 3 working days of a scheduled hospital admission, or within 1 working day following an emergency admission. To request certification for an inpatient admission, contact APS Healthcare toll-free at 1-800-848-8121. Outpatient treatment must be certified for medical necessity when visits exceed 15 per calendar year. To request certification for outpatient treatment, contact the HealthChoice Health Care Management Division at 1-405-717-8879 or toll-free 1-800-543-6044, ext. 8879. For additional information regarding the certification process, reference the Utilization Review section of the HealthChoice Network Provider Manual which is available on the HealthChoice provider website at www.sib. ok.gov/providers, or contact Provider Relations. See Network Provider Contact Information on the back page. *Exceptions to the current 30-day limit are made for the diagnoses of schizophrenia, bipolar disorder/manic-depressive illnesses, major depressive disorder, panic disorder, obsessive-compulsive disorder, and schizo-affective disorder. Sclerotherapy Not a Covered Benefit Beginning with charges incurred on or after February 1, 2012, the HealthChoice fee schedule will show sclerotherapy as NC (Not Covered). Sclerotherapy is considered cosmetic and is not covered by HealthChoice. The following CPT Codes will show NC status: CPT Code Descriptions Allowables 36468 Single or multiple injections of sclerosing solutions; spider veins (telangiectasia); limb or trunk NC 36470 Injection of sclerosing solution; single vein NC 36471 Injection of sclerosing solution; multiple veins, same leg NC Saphenous Vein Ablation-Laser and Radiofrequency will continue to be covered procedures; however, certification is required. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. New Coverage for Non-Network Emergency Room Services 6 Effective for charges incurred on or after January 1, 2012, HealthChoice will reimburse all emergency room services based on Network benefits. The Network benefits for HealthChoice Network Facilities will apply regardless of whether or not a facility is contracted with HealthChoice. All ancillary services provided in an emergency room that occur on the same date of service will also be reimbursed according to Network benefits. To be reimbursed at the Network rate, non-Network facilities must submit claims using Place of Service Code 23. Facilities need to be aware that the $100 emergency room deductible will continue to apply to emergency room services when the patient is not admitted to the hospital. Following are the Revenue Codes that will be affected by the new reimbursement criteria: Revenue Codes Descriptions 450 Emergency Room 451 Emergency Room: ER/Emergency Medical Treatment and Active Labor Act (EMTALA) 452 Emergency Room: ER/Beyond EMTALA 456 Emergency Room: Urgent Care 459 Emergency Room: Other Emergency Room Note: All codes are subject to change. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. FaxBack Feature for Providers HealthChoice providers now have the ability to immediately receive current plan information as well as member eligibility, deductible, and out-of-pocket limit information by fax. This new option is available through FaxBack. FaxBack allows you to enter your fax number and request information be faxed directly to your office. FaxBack documents include: yy A Summary of Benefits for the member’s plan yy Accumulators for the member’s plan yy Certification requirements FaxBack is available 24 hours a day, 7 days a week. To access FaxBack, contact HP customer service at 1-405-416-1800 or toll-free 1-800-782-5218 and follow the prompts of the automated system. Please have the following information available before placing your call: yy Your 10-digit NPI number or 9-digit social security number yy Your fax number yy Member’s identification number yy Member’s date of birth We hope our providers will find FaxBack an easy to use, convenient method for obtaining HealthChoice member information. Fee Schedule Updates HealthChoice and the Department of Corrections (DOC) have updated MS-DRG, MS-DRG LTCH, and outpatient fee schedules. Changes are effective for charges incurred on or after October 1, 2011. The CPT/HCPCS, ASC, ASA, and ADA fee schedules for HealthChoice and DOC have been updated and changes will be effective for charges incurred on or after January 1, 2012. Be aware that HealthChoice and DOC update the CPT/HCPCS, outpatient hospital, ASC, ASA, and ADA fee schedules quarterly. 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. Fee schedule updates are reported in each issue of this newsletter, which is distributed quarterly to Network Providers. Updates are also posted to the provider websites. We encourage you and your staff to reference the website for each Network for the most recent fee schedule updates and other important information. If you have questions, you are welcome to contact the Provider Relations Division. See Network Provider Contact Information on the back page. Fee Schedule Changes for Sealants and Preventive Resin Restorations Effective for charges incurred on or after April 1, 2012, the Allowed Charges for sealant – one tooth (D1351) and preventive resin restoration (D1352) will be revised as indicated below: CDT Code Description Allowable Charge D1351 Sealant – per tooth $31.00 D1352 Preventive resin restoration in a moderate to high caries risk patient-permanent tooth $46.00 Additionally, coverage for preventive resin restoration will be restricted to only permanent teeth; however, there will be no restrictions regarding the age of the patient. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact a Provider Relations specialist. See Network Provider Contact Information on the back page. Providers May Want to Join DOC Network Due to DOC Fee Schedule Mandate Senate Bill 180 was recently signed into law by Governor Fallin. The bill mandates a change to the fee schedule for non-Network providers who provide services to Department of Corrections (DOC) inmates. Effective for charges incurred on or after November 1, 2011, DOC non-Network providers will be subject to the current Medicaid fee schedule. The DOC reimbursement rates for Network Providers are greater than the current Oklahoma Medicaid fee schedule. If you have questions about the DOC fee schedule and how to become a Network Provider for DOC, please contact the Provider Relations Division. See Network Provider Contact Information on the back page or email DOCProviderRelations@ sib.ok.gov. Post Treatment, Breast Symmetry Surgery Effective for charges incurred on or after January 1, 2012, HealthChoice will cover post treatment, breast symmetry surgery following breast-conserving surgery (lumpectomy) when the lumpectomy is medically necessary. All surgeries for post treatment, breast symmetry surgery must be certified through APS Healthcare. Photographs must be submitted for review. If you have questions about this new coverage, please contact the Provider Relations Division at 1-405-717-8790 or toll-free 1-800- 543-6044. To certify a procedure, contact APS Healthcare toll-free at 1-800- 848-8121. 7 Home Health Care Services Effective for charges incurred on or after January 1, 2012, the following HCPCS procedure codes will not be covered when services are provided in an office or outpatient setting: HCPCS Code Description G0151 Physical therapist in home health or hospice setting; each 15 minutes G0152 Occupational therapist in home health or hospice setting; each 15 minutes G0153 Speech/language pathologist in home health or hospice setting; each 15 minutes G0154 Skilled nurse in home health or hospice setting; each 15 minutes G0155 Clinical social worker in home health or hospice setting; each 15 minutes G0156 Home health or hospice aide in home health or hospice setting; each 15 minutes S0274 Nurse practitioner visit at member’s house, outside of a capitation arrangement One CPT/HCPCS code will be allowed per home health care provider per day for the following codes when services are provided in an office or outpatient setting: CPT/HCPCS Code Description 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring 99501 Home visit for postnatal assessment and follow-up care 99502 Home visit for newborn care and assessment 99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation) 99504 Home visit for mechanical ventilation care 99505 Home visit for stoma care and maintenance including colostomy and cystostomy 99506 Home visit for intramuscular injections 99507 Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral) 99509 Home visit for assistance with activities of daily living and personal care 99510 Home visit for individual, family, or marriage counseling 99511 Home visit for fecal impaction management and enema administration 99512 Home visit for hemodialysis 99600 Unlisted home visit service or procedure 99601 Home infusion/specialty drug administration, per visit (up to 2 hours) S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PCC), nursing services only (no supplies or catheter included) S5523 Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included) S9097 Home visit for wound care S9098 Home visit, phototherapy services (e.g. Bil-lite), including equipment rental, nursing services, blood draw, supplies, and other services, per diem S9122 Home health aide or certified nurse assistant, providing care in the home, per hour S9123 Nursing care, in the home, by registered nurse, per hour S9124 Nursing care, in the home, by licensed practical nurse, per hour continued on next page 8 9 Changes to the Certification List for 2012 For charges incurred on or after January 1, 2012, HealthChoice is making some changes to its current list of procedures and/or services that require certification. The following will be added to the list of services requiring certification: yy Spinal Cord Stimulator Placement Surgery (CPT Codes 63650, 63655, 63661, 63662, 63663, 63664, 63685 and 63688, and HCPCS Codes L8682, L8685, L8686, L8687 and L8688) The following will be removed from the list of services requiring certification: yy PET Scans for Tumor Imaging (CPT Codes 78811, 78812, 78813, 78814, 78815 and 78816) yy Speech Therapy for plan members and their covered dependents 18 years of age or older (CPT Codes 92507 and 92508, and HCPCS Codes S9128 and S9152) yy Xolair Injection, omalizumab 5mg (J Code J2357) Note: All CPT/HCPCS codes are subject to change. Please direct questions about the certification process to the HealthChoice Provider Relations Division at 1-405-717-8790 or toll-free 1-800-543-6044. Questions can also be sent to Provider Relations by email to oseegibproviderrelations@sib.ok.gov. Department of Rehabilitation Services Recruiting Providers The Department of Rehabilitation Services (DRS) is in the process of recruiting providers for its Network. DRS is the state agency that provides vocational rehabilitation to disabled individuals to help them become more independent, productive members of the Oklahoma workforce. If you are interested in learning more about DRS, please visit the DRS Network Provider website at https://gateway.sib.ok.gov/DRS. To access the DRS fee schedule, simply click Fee Schedule in the top menu bar. If you are interested in joining the DRS Network, contracts are available under the Contracts tab in the top menu bar. Please send email inquiries to DRSProviderRelations@sib.ok.gov or contact DRS Provider Relations at 1-405-717-8921 or toll-free 1-888-835-6919. Benlysta® Treatment Requires Certification Benlysta® (belimumab) is a new intravenous medication used to treat lupus in adults. HealthChoice requires providers to obtain certification through its Health Care Management Division before beginning treatment with this medication. To certify treatment with this medication, providers must complete and submit a Benlysta® Request Form for approval. This form is available on the provider website at www.sib.ok.gov/providers. S9125 Respite care, in the home, per diem S9126 Hospice care, in the home, per diem S9127 Social work visit, in the home, per diem S9128 Speech therapy, in the home, per diem S9129 Occupational therapy, in the home, per diem S9131 Physical therapy, in the home, per diem Units billed will be allowed for the following code when services are provided in an office or outpatient setting: CPT Code Description 99602 Home infusion/specialty drug administration, per visit (up to 2 hours) each additional hour Note: All CPT/HCPCS codes are subject to change. Certification for home health care services is required through the HealthChoice Health Care Management Division. See Network Provider Contact Information on the back page. If you have questions regarding this issue, contact HealthChoice Provider Relations. See Network Provider Contact Information on the back page. continued from previous page 10 HealthChoice, DOC, DRS to Adopt Electronic Claims Payments 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). Effective July 1, 2012, any provider who has not authorized EFT for their contract will be at risk for delayed claims payments. EFT is fast and secure, and reimbursements are deposited directly to the bank account you designate. You will continue to receive paper remittance advices (RAs) to assist with accounts reconciliation. Practice groups that use the same bank account for multiple providers under the same TIN need to submit only one form to OSEEGIB along with a list of their affiliated providers. The HealthChoice, DOC, and DRS electronic funds transfer and online RA programs offer these advantages: yy Claim payments are automatically deposited yy RAs can be searched online through ClaimLink yy Access to current and historical RAs through ClaimLink yy Less paper handling All you have to do is complete the form and return it to OSEEGIB as indicated. We will take care of the rest. Enhance your cash flow management and sign up today for EFT! The EFT Authorization Form is available from the following websites: yy http://www.ok.gov/sib/ Providers/Provider_Forms/ index.html yy https://gateway.sib.ok.gov/ DOC/Forms.aspx yy https://gateway.sib.ok.gov/ drs/Forms.aspx You’ll need to allow two to four weeks for your registration to be processed, so don’t wait until the last minute to sign up! If you have any questions, please contact Provider Relations at 1-405-717-8790 or toll-free 1-800- 543-6044, or send email inquiries to oseegibproviderrelations@sib. ok.gov. New! Provider Applications Can Be Completed Online Providers now have the ability to complete and submit the HealthChoice, DOC, and DRS Network Provider Applications online. In order to submit an application online, you must have the ability to email an electronic signature to HealthChoice Provider Relations. If you don’t have an electronic signature, the Health Insurance Prospective Payment System HealthChoice will accept Health Insurance Prospective Payment System (HIPPS) Codes effective February 1, 2012. These HIPPS Codes will be recorded for reporting purposes only. Please direct email inquiries to oseegibproviderrelations@ sib.ok.gov or contact Provider Relations. See Network Provider Contact Information on the back page. application can be completed, scanned, and then emailed to OSEEGIBproviderrelations@sib. ok.gov. If this is not an option for you, complete the application and mail it to: HealthChoice Provider Relations Division 3545 NW 58 Street, Suite 110 Oklahoma City, OK 73112 Or fax your application to 1-405-717-8977. If you have questions or need more information, please contact HealthChoice Provider Relations. See Network Provider Contact Information on the back page. Timely Claims-Filing Deadline Waived for Coordination of Benefits For charges incurred on or after February 1, 2012, HealthChoice will waive the timely claims-filing deadline as it applies to Coordination of Benefits for providers who file standard HIPAA 837 claims. Please email questions to HealthChoice Provider Relations at oseegibproviderrelations@sib.ok.gov or contact HP Administrative Services, LLC at 1-405-416-1800 or toll-free 1-800-782-5218. 11 Medications Now Available in Generic Form New generic medications are now available for the brand-name medications listed below. If you prescribe any of these brand-name medications to HealthChoice members, please note that the generic medication saves them money at the pharmacy. This applies to all HealthChoice members, including all members of the HealthChoice Medicare Supplement Plans With and Without Part D. Brand-Name Medication Generic Medication Treatment Launch Date Alsuma sumatriptan injection Migraine/cluster headaches Aug 2011 Amrix cyclobenzaprine HCL extended-release capsules Muscle relaxant May 2011 Aromasin exemestane Breast cancer Apr 2011 Carbatrol carbamazepine Epilepsy or nerve pain May 2011 Concerta methylphenidate hydrochloride extended release tablets ADHD May 2011 Elestat Ophthalmic epinastine HCL ophthalmic solution Allergic conjunctivitis May 2011 Femara letrozole 2.5mg tablets Breast cancer Apr 2011 Femcon Fe norethindrone and ethinyl estradiol Birth control Apr 2011 FemHrt 1-5 ethinyl estradiol and norethindrone Hormone replacement Feb 2011 Furadantin Suspension nitrofurantoin Antibiotic - urinary tract infection June 2011 Levaquin levofloxacin Antibiotic June 2011 Lotrel 5/40 & 10/40mg amlodipine besylate/benazepril HCL Hypertension Jan 2011 Lybrel levonorgestrel and ethinyl estradiol Birth control June 2011 Nasacort AQ triamcinolone acetonide Nasal allergy symptoms June 2011 Nitrolingual Pump Spray glyceryl trinitrate Heart (blood flow) Mar 2011 Prenate Essential PNV with CA#68/Iron Pregnancy – nutritional supplement June 2011 PreNexa PNV66/iron fumarate Pregnancy – nutritional supplement June 2011 Rythmol SR propafenone SR 225mg, 325mg, 425mg capsules Abnormal heart rhythm Jan 2011 Seasonique ethinyl estradiol & levonorgestrel Birth control Aug 2011 Sular 8.5m 17, 25.5 & 34mg nisoldipine High blood pressure Jan 2011 Uroxatral alfuzosin hydrocholoride Benign prostatic hyperplasia July 2011 Vfend voriconazole 50 & 20mg Serious fungal infections Feb 2011 Xalatan latanoprost ophthalmic solution Glaucoma Mar 2011 This publication is printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance as authorized by 74 O.S. , Section 1301. 4,000 copies have been printed at a cost of $0.35 each. Copies have been deposited with Publications Clearinghouse of the Oklahoma Department of Libraries. He lthChoice Provider Network News 3545 NW 58 Street, Suite 110 Oklahoma City, OK 73112 www.sib.ok.gov www.healthchoiceok.com Presorted First-Class U. S. Postage PAID Permit #1067 Okla. City, OK Network Provider Contact Information DOC Provider Relations https://gateway.sib.ok.gov/DOC OKC Area 1-405-717-8750 Toll-free 1-866-573-8462 DOC Health and Dental Claims HP Administrative Services, LLC P. O. Box 268928 Oklahoma City, OK 73126-8928 Toll-free 1-800-262-7683 DRS Provider Relations https://gateway.sib.ok.gov/DRS OKC Area 1-405-717-8921 Toll-free 1-888-835-6919 DRS Health and Dental Claims HP Administrative Services, LLC P.O. Box 25069 Oklahoma City, OK 73125-0069 Toll-free 1-800-944-7938 HealthChoice Providers www.sib.ok.gov www.healthchoiceok.com Health and Dental Claims HP Administrative Services, LLC P.O. Box 24870 Oklahoma 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 Medco Health Solutions Pharmacy 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 1-405-416-1755 HealthChoice Health Care Management Division OKC Area 1-405-717-8879 Toll-free 1-800-543-6044 Ext. 8879 HealthChoice Provider Relations OKC Area 1-405-717-8790 Toll-free 1-800-543-6044 |
Date created | 2011-11-17 |
Date modified | 2011-11-22 |
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