oklahoma medicaid provider manual


Network providers can request a second level appeal if the initial appeal is upheld and the network provider has additional information to submit for review. a) OHCA is the single state agency that the Oklahoma Legislature has designated through 63 Okla. Stat. Your Provider Manual to the New York Medicaid Program offers you a wealth of information about Medicaid, as well as specific instructions on how to submit a claim for rendered services. Contact lenses are covered only for the diagnosis of keratoconus, an uncommon condition of the eye surface. A fee schedule will be adopted for ambulance HCPCS billing codes. Maximum of 60 visits allowed per calendar year. You may have multiple NDCs when you administer multiple drug strengths to a patient or when a drug is comprised of more than one ingredient. This guide discusses how rebranding impacts providers and their patients. Fax: 855-532-6780. Speech therapy services are also considered medically necessary for assessment and treatment of the diagnoses of pervasive developmental disorders (PDD) when the member meets any of the following criteria: A request for a speech therapy evaluation for members 17 and younger must include a copy of the prescription or referral from a physician with documentation of the diagnosis. Revision Date: January 2014. HealthChoice will have 45 days after submission to reach a determination. Version 6.1. No two-word spontaneous (not just echolalia) phrases by 24 months. Provider to contract for healthcare services to be provided to members in Oklahoma Medicaid, known as SoonerCare, programs. 8879  Any routine hygienic foot/hand care, including trimming nails, and any other service rendered in the absence of localized illness, injury or symptoms involving the feet or hands. If you have questions or want to obtain certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Box 3897 Provider Manuals. Following is a brief description of the rules that apply: HealthChoice allows the billed charge or allowed amount, whichever is less, of the set copay up to the out-of-pocket maximum. The Select program is designed to reduce the costs of select services by contracting with select medical facilities to provide these services and bill HealthChoice for a single amount for all associated costs on the date the surgery or procedure is performed. The below services require certification through the HealthChoice Certification Administrator. Most providers who are licensed and/or certified in their particular state are eligible to participate in the Provider Network. Interceptive orthodontic treatment of the primary dentition. Revision Date: November 2017. PA Forms and Policies. Bureau of Health Services Financing. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and failing to use the primary plan’s preferred provider arrangements. If further clarification is needed, please contact the claims administrator toll-free 800-323-4314. Under the Medicaid Home and Community-Based Waiver ADvantage Program, the Oklahoma Department of Human Services, Division of Aging Services, offers services to eligible adults as an alternative to care in a nursing facility. The HealthChoice plans are a partnership between providers, members and EGID in the delivery of health and dental care services and products that helps control costs, assists in the provision of high-quality health and dental care, and enhances provider-patient relationships. Schedule for release of funds to providers. HealthChoice is contracted with SilverScript to provide Medicare Part D benefits. It is imperative providers inform network management when contact information of any type is updated. Claims that are not in compliance are either rejected or denied. Claims submitted later than 365 days from the date of service. Interceptive orthodontic treatment of the transitional dentition. Wrongful act or negligence of another when an employee or dependent has released the responsible party, unless subrogation has been waived or reduced in writing in an individual case, solely at EGID’s option, and only for good cause. There is also the option of mail service. Title 36 O.S. Make sure they are filing your claims electronically and not on paper; it takes much longer to process paper claims. HealthChoice plan members have the ability to use health care providers from a wide range of specialties. 2401 N Lincoln Blvd. All payment information, explanation of provider payment (EPP), and ERA will be available at ECHO Health’s multipayer portal, As related to reimbursement, per diem represents each day that a patient is provided a prescribed visit. Each claim will be reviewed for coverage. HealthChoice covers orthodontic services for members under the age of 19; and for members ages 19 and older with temporomandibular joint dysfunction. We also added a new Chapter 3, which contains additional filing requirements, such as prior Limit of 20 visits allowed per calendar year without certification (refer to Speech Therapy for certification exception information). To distribute the newsletter as efficiently as possible, it is distributed electronically to each network provider’s correspondence email address. Required for specified medications covered under the HealthChoice medical plan; this is not inclusive of requirements under the HealthChoice Pharmacy Benefits Administrator. Required only after initial 20 visits per calendar year. Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits. The direct data entry feature allows providers to submit individual medical, dental or hospital claims directly to the claims administrator. Visits limited to 60 total per calendar year (some exceptions apply). 8879. It is important providers receive communication from network management, so please make sure security settings allow this information to be accepted. TTY users call 711. Assist with and adhere to all aspects of the benefits offered through HealthChoice. Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee. Lubbock, TX 79490-9011, HealthChoice The network management unit is responsible for developing the content of the Network News newsletter. For medical records requests, please visit our webpage. HealthChoice will acknowledge and pay telehealth claims according to the CPT, HCPCS and outpatient fee schedules. Required initially for Applied Behavior Analysis services. Fax a prior authorization form to the provider’s office. Oklahoma City, OK 73105, 405-717-8790  Physical therapist in home health or hospice setting; each 15 minutes, Occupational therapist in home health or hospice setting; each 15 minutes, Speech/language pathologist in home health or hospice setting; each 15 minutes, Clinical social worker in home health or hospice setting; each 15 minutes, Home health or hospice aide in home health or hospice setting; each 15 minutes, Nurse practitioner visit at member's house, outside of a capitation arrangement. Anesthesia assistant is 50% of allowable fee. Use the current claim form to expedite claims processing. Orthodontic benefits can be complicated, but to simplify the benefit for your ease of use, the chart below lists what is covered, not covered and what is all-inclusive. Place the NDC information in the line’s top shaded part. Would like to automate the ERA delivery through your preferred clearinghouse partner. Oklahoma Medicaid Spend Down. Disclaimer. Oklahoma City, Ok 73111 Arkansas Medicaid has released a Final Rule for SPA Amendment 2020-0021 Therapy Changes and Amendments to the Occupational, Physical, and Speech-Language Therapy Services Medicaid Provider Manual, with Related Changes to ARKids First- B, Hospital, Rehabilitative Hospital, Prosthetics, Home Health, Physician, and Nurse Practitioner Provider Manuals. Issued July 1, 2011 . Second level appeals are only available to network providers. MHCP Provider Manual – Home. Explore the Medical and Pharmacy Policies that are used as guidelines to determine coverage in benefits programs. Under the combined payments feature, all payments for a given day are combined into a single remittance advice for a single provider. A) EGID will be applying similar bundling logic to its outpatient hospital claims beginning Jan. 1,2019. Bill with the NDC code and the corresponding CPT/HCPCS code. You can obtain a copy of the official rules from the office of the Oklahoma Secretary of State. The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. Have HealthChoice as the second or third carrier. Network management will provide the Attachment A with applicable services upon request. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary. The provider receives an immediate response regarding the status of the claim with real time responses indicating if the claim has been paid, denied or suspended. Oklahoma Department of Human Services 2400 N Lincoln Boulevard. • State Medicaid has no explicit policy regarding transgender health coverage and care • See West Virginia Medicaid Provider Manual, Ch 100 (since at least 2005) Wisconsin • State Medicaid policy explicitly covers transition-related health care • Explicitly excluded in 1996 (see DHS 107.03), until 2019 ruling (Flack v. Wisconsin Both are required on the claim for accurate reimbursement. Disclaimer: The Oklahoma Health Care Authority (OHCA) is providing this material as an informational reference for physicians and non-physician practitioners-providers. The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. Important Notices to Providers Provider Manual Update. To update email information, network providers can use the appropriate change form located on the Provider Forms webpage. Table of Contents. New claims, medical records, correspondence and corrected claims should be submitted to: HealthChoice  The contracts require network providers to make a reasonable effort to refer HealthChoice members and their dependents to other network providers when additional consults are necessary. Box 52136 Examples include, but are not limited to:  braces, compression garments, room humidifiers, air purifiers, pulse oximeters, blood pressure cuffs, exercise equipment, swimming pools, Jacuzzi pumps, saunas, hot tubs, automobiles or adaptive equipment for automobiles, sun lamps, augmentative communication devices, patient lifts, adaptive bathroom and self-care equipment, assistive devices, and cold/cryotherapy devices. Find a Provider. HealthChoice Plan members have the ability to utilize health care providers from a wide range of specialties. Resubmit a claim only if it is not already on file. Field 42: Include the appropriate revenue code. Plan members cannot realize the full benefit of their HealthChoice plan unless they utilize network providers. Provide evidence of coverage in the form of a HealthChoice ID card. Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery. Arkansas Medicaid has released a Final Rule for SPA Amendment 2020-0021 Therapy Changes and Amendments to the Occupational, Physical, and Speech-Language Therapy Services Medicaid Provider Manual, with Related Changes to ARKids First- B, Hospital, Rehabilitative Hospital, Prosthetics, Home Health, Physician, and Nurse Practitioner Provider Manuals. The HealthChoice Provider Network is comprised of over 15,000 health care practitioners and facilities. Tobacco cessation counseling outside preventive service benefit coverage. The plan maximum is 60 speech language pathology visits each calendar year. All provider remittance advices and 835 transactions will reflect the accurate copay amount. Managed Care in Oklahoma – Medicaid. This newsletter is a quarterly publication specifically for network providers. Provider Tools. HealthChoice excludes telepharmacy networks that use pharmacists to provide services. The claim must include the banding date and the length of treatment in months. Help improve clean claim rates and increase collections with actionable edit intelligence. Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient. BR3: 0% of billed charges for Tiers 1, 2, 3 and 4. Mar 9, 2015 … OHCA Provider Billing And Procedure Manual. Cosmetic or elective surgical procedures, treatments or drugs not necessary as the result of an accident with continuous coverage from the date of the accident to the date of corrective surgery. Any expense that a provider is prohibited (by law or by contract) from charging a covered person is not an allowable expense. Bariatric surgical services obtained from any facility that is not a HealthChoice bariatric network provider. Electronic Health Record Incentive Program, SoonerCare Out-of-State Services Rule Changes, For Internet/EVS PIN resets or assistance with SoonerCare Secure Site, For assistance with EDI batch transactions, For questions concerning paid claim adjustments or outstanding A/R inquiries, For health insurance injury/accident questionnaires, third party insurance inquiries, estate recovery or subrogation issues, OHCA Level of Care Evaluation (PASSR for persons with possible mental illness), OKDHS, Children & Family Services Division, OKDHS, Developmental Disabilities Division, Long Term Care Authority (ADvantage Waiver), Oklahoma Department of Mental Health and Substance Abuse Services. As a reminder, HealthChoice covers only the following laboratory urine drug screens when medically necessary screening tests are required: HealthChoice covers the following presumptive (qualitative) and definitive (quantitative) laboratory urine drug screenings when medically necessary. For all infusion therapy charges, certified home skilled nursing visits are not included in the HealthChoice allowed amount, but can be billed separately. The following is a comprehensive list of benefits for telehealth services available through network providers: All plan policies and provisions apply including HealthChoice claim editing guidelines. Procedures covered at 100% of allowable fees. Providers may check the OHCA Recipient Eligibility Verification System (REVS) at (800) 522-0310. Oklahoma Medicaid Billing Manual 2019. If at any point in the treatment it is determined that expectations will not be met, services will no longer constitute coverage for speech language pathology services. The below services require certification through the HealthChoice Health Care Management Unit. Professional services only require the use of POS 02. Limited orthodontic treatment of the transitional dentition. HealthChoice requires verification of other insurance on a rolling 12-month basis. Information and forms to enroll as an Alabama Medicaid provider. ADDT providers may furnish and claim reimbursement for covered ADDT services subject to all requirements and restrictions set forth and referenced in the Arkansas Medicaid provider manual. Speech therapy for learning disabilities or birth defects. Implants that are billed with just a UB-revenue code are not paid separately and arebundled into the J1 procedure fee. TTY users call 711. If you consistently have issues with the claims that do not process quickly, please verify the format your intermediary or clearinghouse uses to submit your claims. Dental providers can register for this service through DentalXChange. Note: For a prompt reply, providers must send all written inquiries regarding contract information or any documentation intended for the network management staff directly to network management at the mailing address, email address or fax number referenced above. 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