Global Messages

/images/web_alerts.jpg

2014 Global Messages
2013 Global Messages
2012 Global Messages
2011 Global Messages
2010 Global Messages
2009 Global Messages
2008 Global Messages
2007 Global Messages
2006 Global Messages 

 

 Date Posted Title
 Message
8/25/2016 Unbundling of Obstetrical (OB) Services Delayed

Title: Unbundling of Obstetrical (OB) Services Delayed

Run Dates: 8/26/16-10/10/16

PV TYPES: ALL

 

OHCA will be delaying the OB unbundling changes reflected in provider letter 2016-20 that were going to become effective September 1, 2016. If you have any questions, please call the OHCA call center at 1-800-522-0114.

8/24/2016 Dear Provider Letter 2016-24

New Global Message:

Title: Dear Provider Letter 2016-24

Run Dates:  8/19/2016-10/3/2016

PV Types:   05

 

Provider Letter 2016-24 serves to inform providers about face to face requirements for Home Health Services, effective immediately. Please post all comments by close of business, Thursday, September 22, 2016 via the policy change blog. Thank you for your participation in this process.

8/22/2016 Autonomic Function Testing Reimbursement Changes  

Title:                  Autonomic Function Testing Reimbursement Changes

Run Date:         08/18/2016 – 10/01/2016

PV Types:         08, 09, 10, 31, 52

 

Effective September 1, 2016, OHCA will no longer reimburse for CPT code 95943. As per CMS guidelines, OHCA considers parasympathetic and sympathetic heart rate testing described by CPT 95943 to be a component of an initial neurologic assessment. This code was not developed and intended to be specific to any brand/manufacturer. If a provider finds that this non-standardized component information of autonomic function testing is useful in a patient assessment and clinical decision making given certain patient risks/signs/symptoms, this would be included in the physician’s basic evaluation and management service and not separately covered.      

Also effective September 1, 2016, reimbursement for CPT codes 95921 and 95922 will be restricted to the following provider types only: 312-Cardiologist, 326-Neurologist, 523-Child Neurology and 550-Pediatrics Cardiology as per recommended guidelines.     

95921 - testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ration and 30:15 ration.    

95922 - testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt.     

95943 - simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, passed (deep) breathing, Valsalva maneuvers, and head-up postural change).

8/17/2016 Enteral Nutrition Changes to PA Process  

Title:          Enteral Nutrition Changes to PA Process

Run Dates:     08/17/2016 – 12/31/2016

PV Types:       250 – DME/Medical Supply Dealers

 

Effective immediately, all enteral prior authorization (PA) requests to the Oklahoma Health Care Authority (OHCA) may be requested to cover a time period up to a maximum of one year. We have determined that this change will reduce your workload, OHCA staff workload and extend the PA period by an additional six months.   

To increase, decrease or change enteral formula of an active approved PA, please submit changes as an amendment to the PA for review.

If you have questions regarding this process, please email DMEADMIN@okhca.org for a response from the OHCA Durable Medical Equipment (DME) Team. Thank you.

8/16/2016 Dear Provider Letter 2016-25

Title: Dear Provider Letter 2016-25

Run Dates: 8/16/2016 -10/01/2016

PV Types:   03, 36, 38, 163

 

Provider Letter 2016-25 informs providers about ordering, referring, and rendering. It provides additional guidance for Provider Letter 2013-44 and the global notification for CMS Federal Requirement for Ordering and Referring. Please post all comments by close of business, Thursday, September 15, 2016, via the Policy Change Blog. Thank you for your participation in this process.

8/16/2016 Unbundling Obstetrical Services Training Opportunity Title:                            Unbundling Obstetrical Services Training Opportunity
 
Run Dates:                 08/16/2016 – 08/26/2016
 
PV Types:                  All

Obstetrical (OB) services policy at OAC 317:30-5-2 and 317:30-5-22 is revised to amend the reimbursement structure for OB services. Currently the agency utilizes the global care CPT codes for routine OB care billing, which can be used if the provider rendered care for a member for greater than one trimester.     

The revised policy will require OB care be billed using the appropriate evaluation and management codes for antepartum care, as well as the appropriate delivery-only and postpartum care services when rendered.

For full details regarding this revision, please reference Provider Letter 2016-20, which can be found at www.okhca.org/providerletters.

We are offering a webinar to help providers understand and prepare for this revision. The webinar will be on August 24, 2016, at 2 p.m. OHCA recommends this presentation for all providers who provide and bill for OB services. We will also address your questions at that time.

Please register by going to: http://okhca.org/provider-training.
8/15/2016 Complex Rehab Technology Provisions  

Title:        Complex Rehab Technology Provisions

Run Dates:    08/12/2016 – 12/31/2016

PV Types:      250 – DME/Medical Supply Dealers

 

State law has been passed to establish focused regulations for products and services classified as CRT (Complex Rehab Technology). Effective September 1, 2016, a CRT code set will be limited to those providers who meet the CRT specific supplier standards.  The revisions establish requirements and restrict the provision of CRT to only qualified suppliers. See Provider Letter 2016-10 dated July 29, 2016.

The new specialty provider type will be 252 – Complex Rehab Technology Supplier.  Requirements include the following:

1)  Eligible providers must be Accredited to dispense CRT

2)  Eligible providers must be contracted with Medicare

3)  Eligible providers must employ a CRT professional as a W-2 employee

4)  Eligible provider must comply with RESNA standards

 

If your company meets the qualification and have an interest in applying for the Specialty Code; please contract Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org for additional clarification. 

8/1/2016 New Dear Provider Letters  

Title:       New Dear Provider Letters

Run Dates:   08/01/2016 – 09/15/2016

PV Types:    All

 

Provider Letters 2016-09 through 2016-19, as well Provider Letter 2016-23, outline OHCA program and policy updates that will become effective September 1, 2016.  For full details about these changes, please visit www.okhca.org/providerletters.

7/29/2016 Email for PA Inquiries Title:                      Email for PA Inquiries
 
Run Dates:          07/29/2016 – 09/15/2016
 
PV TYPES:           250 – DME/Medical Supply Dealers

The Oklahoma Health Care Authority (OHCA) has a new email address for DME suppliers to use for inquiries related to DME prior authorizations (PAs): DMEADMIN@okhca.org. Please use this email address to contact us about your PA questions instead of contacting the OHCA Help Desk.
 
Since the Provider Portal provides notes that explain the review by our DME staff, we expect that suppliers will access those PA notes prior to submitting an email inquiry.
(An email is a last resort to resolve the PA inquiry.) The goal is to centralize the inquiries for DME suppliers in our effort to provide clarification on the PA decisions made.
 
We will send responses made by DME staff via secure email to insure HIPAA compliance with protected health information (PHI).
 
Thank you for your consideration.
 
Contact Stan Ruffner, DMEPOS director, at stan.ruffner@okhca.org for additional clarification.
7/29/2016 Dear Provider Letter 2016-17

Title: Dear Provider Letter 2016-17

Run Dates: 7/28/16-9/10/16

PV Types:   019, 082, 085, 088, 180, 183, 188, 196, 330, 345, 543

 

Provider letter 2016-17 outlines OHCA Program and Policy Updates regarding optical supplies that will become effective September 1, 2016. Please post all comments by close of business Monday, August 29, 2016, via the Oklahoma Health Care Authority (OHCA) Policy Change Blog. Thank you for your participation in the process.  
7/28/2016 Ordering & Referring Training Opportunities  

Title:      Ordering & Referring Training Opportunities

Run Date:   07/22/2016 – 09/10/2016

PV Types:   All

42 CFR § 455.440, requires that all payment claims for items and services that were ordered/referred contain the National Provider Identifier (NPI) of the physician or other professional who ordered/referred such items or services.

Due to the high demand of our previous two webinars on this topic, the Oklahoma Health Care Authority (OHCA) is offering additional training to help providers understand and meet these requirements. Webinars are August 10, 2016, at 2 p.m. and August 18, 2016, at 2 p.m. OHCA recommends these webinars for all SoonerCare providers who order or refer services and those providers who receive orders or referrals.

Learn what information is required, how to use the SoonerCare Provider Portal to transmit this information, and the proper way to submit claims that meet this requirement. Time will also be given to address your questions.

To register, please visit http://okhca.org/provider-training.

For questions, please contact OHCA Provider Services at 1-800-522-0114, option 1.

7/28/2016 Dear Provider Letter 2016-22  

Title: Dear Provider Letter 2016-22

Run Dates: 7/28/2016 - 9/10/2016

PV TYPES: 451

Provider letter 2016-22 outlines OHCA program and policy updates to therapeutic foster care that will become effective September 1, 2016. Please post all comments by close of business Monday, August 29, 2016, via the Oklahoma Health Care Authority (OHCA) Policy Change Blog. Thank you for your participation in the process.

7/28/2016 Dear Provider Letter 2016-21 Title: Dear Provider Letter 2016-21
 
Run Dates: 7/28/16-9/10/16
 
PV Types:   01, 02, 08, 09, 10, 13, 16, 28, 31, 52, 57

Provider letter 2016-21 serves to inform providers on the prior authorization of molecular pathology CPT codes related to hereditary cancer susceptibility testing, effective September 1, 2016. Please post all comments by close of business Monday, August 29, 2016, via the the Oklahoma Health Care Authority (OHCA) Policy Change Blog.

Thank you for your participation in the process.
7/28/2016 Critical Incident Reporting  

Title:    Critical Incident Reporting

Run Date: August 1, 2016 to September 15, 2016

PV Type: 01

    Spc: 013, 015

 

As required by OAC 317:30-5-95.39 an Section 42 CFR_483.374(c), psychiatric residential treatment facilities (PRTFs) providing services for members under age 21 must submit critical incident reports to the Oklahoma Health Care Authority (OHCA) as part of their established provider agreement.    

Critical incidents, as defined by OAC 317:30-5-95.39, includes death, serious injury or suicide attempt. PRTFs must also report SoonerCare member deaths to the Centers for Medicare and Medicaid Services (CMS) regional office in Dallas, Texas.    

The hospital administrator, executive director or designee is required to contact the OHCA Behavioral Health Unit by phone no later than 5 p.m. on the business day following the incident. The report must include the name of the SoonerCare member involved, the basic facts of the incident, and the facility’s follow-up procedures in regard to the incident. The OHCA Behavioral Health Unit must receive the above information in writing within three (3) business days (Ex: facility critical incident report).    

Please fax your critical incident reports directly to OHCA at 405-530-7260.    

For questions, please contact the OHCA Behavioral Health Operations Unit at 405-522-7017.

7/26/2016 Unbundling Obstetrical Services

TITLE:    Unbundling Obstetrical Services

Run Date: 07/26/2016 – 09/15/2016

PV Type:  All

  

Obstetrical (OB) services policy at OAC 317:30-5-2 and 317:30-5-22 is revised to amend the reimbursement structure for OB services. Currently the agency utilizes the global care CPT codes for routine OB care billing, which can be used if the provider rendered care for a member for greater than one trimester.     

The revised policy will require OB care be billed using the appropriate evaluation and management codes for antepartum care, as well as the appropriate delivery-only and postpartum care services when rendered. The change allows for more accurate tracking of antepartum and postpartum services.     

Effective September 1, 2016, all global OB CPT codes will not be eligible for reimbursement. This includes CPT 59400, 59410, 59425, 59426, 59510, 59515, 59610, 59614, 59618 and 59622.    

There will be two different billing periods for OB care - one for services rendered up to August 31, 2016, and another for services rendered from September 1, 2016, forward.     

For full details, please reference Provider Letter 2016-20, which can be found at www.okhca.org/providerletters. 

7/25/2016 Ordering Provider on Medicare Crossover Claims  

Title:     Ordering Provider on Medicare Crossover Claims

Run Date:  07/18/2016 – 09/05/2016

PV Type:   All

 

Due to a recent system change, our system now captures Medicare Crossover claim detail-level data and pays the claim at the detail level. In the past the Oklahoma Health Care Authority (OHCA) paid the entire claim at the header level, so no ordering provider was required. If the provider does not include the ordering physician on the Medicare claim, then the crossover claim will deny with an error stating that there is no ordering physician listed (edit 1138).     

For claims that have denied for this reason, providers must void the claim, list the ordering provider, and resubmit.    

The provider can only void a claim if it is paid status.They can have a paid claim with details that denied for this reason, which is why they would need to void the claim, correct the denial and refile a new claim.     

If you have questions regarding these changes, please contact OHCA Provider Services at 1-800-522-0114, option 1.

7/15/2016 TFC Rendering Provider Enrollment  

TITLE:    TFC Rendering Provider Enrollment

Run Date: 07/15/2016 – 08/01/2016

PV Type:  45

 

Beginning August 1, 2016, therapeutic foster care agencies submitting claims for payment to OHCA are required to include the rendering providers assigned to their Oklahoma Medicaid Group ID on the claim. The rendering service provider is appointed to the stated group (therapeutic foster care agency) for receipt of payment for Medicaid-compensable health care services and directs the OHCA to make all such payments to the group. This is regardless of any other agreement the rendering provider has with the OHCA. OHCA does not make direct payments to the rendering provider.    

After August 1, 2016, therapeutic foster care agencies that do not submit rendering providers on their claims will receive denials in the claims system for payment.     

You may fax your Appendix A directly to 405-530-3454.    

For questions, please call 1-800-522-0114 and select option 5.

7/11/2016 Electronic signatures accepted for 2016 EHR attestations

Title:                Electronic signatures accepted for 2016 EHR attestations

Run date:        07/11/2016 – 08/26/2016

PV Types:       31, 52, 09, 27, 10

 

The OHCA EHR Incentive Team would like to announce that electronic signatures will be accepted starting 7/7/2016. It will no longer be required to submit the SoonerCare Provider Agreement Signature Form with your uploaded documentation.

If you have questions or need more information please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org, or visit our website: www.okhca.org/ehr-incentive.

If you have any questions or need more information on the upload process, please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org or visit our website: www.okhca.org/ehr-incentive.

7/11/2016 Updates to HIPAA Adjustment Reason Codes  

Title:         Updates to HIPAA Adjustment Reason Codes

Run Dates:    07/11/2016 – 08/23/2016

PV Types:     All

 

We wanted to inform you that the Oklahoma Health Care Authority (OHCA) is updating the Explanation of Benefits (EOBs) and the HIPAA Adjustment Reason Codes you receive on your remit and 835. These changes are to provide better information on claim denials. Updates should be complete by the end of July 2016.

If you have questions regarding these changes, please contact OHCA Provider Services at 1-800-522-0114, option 1.

7/6/2016 Ordering & Referring Training Opportunities

Title:       Ordering & Referring Training Opportunities

Run Dates:   07/06/2016 – 08/01/2016

PV Types:    All

 

42 CFR § 455.440, requires that all claims for payment for items and services that were ordered or referred contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services.

We are offering two webinars that will focus on helping providers understand and meet these requirements.  The webinars will be on July 14 at 2 p.m. and July 21 at 2 p.m. and are recommended for all SoonerCare Choice Patient Centered Medical Homes, providers that order services and providers that receive orders or electronic referrals.

Providers will learn about the information that is required, how to use the SoonerCare Provider Portal to transmit this information and how to appropriately submit claims that meet this requirement. Time will also be given to address your questions.

Please register by going to: http://okhca.org/provider-training

If you have any questions, you may also contact Provider Services at 1-800-522-0114, option 1.

7/6/2016 Dear Provider Letter 2016-08

Title: Dear Provider Letter 2016-08

Run Date: 7/6/2016 thru 8/19/2016

PV Types:   080, 081, 083, 084, 091, 181, 184, 185, 199, 328, 335

 

Provider letter 2016-08 serves to inform providers on the expanding coverage of Makena and vaginal progesterone, effective August 1, 2016. Please post all comments by close of business, Friday, August 5, 2016, via the policy change blog. Thank you for your participation in the process.

6/30/2016 New Cesarean Section Rates Retrieval Process

Title:                      New Cesarean Section Rates Retrieval Process

Run Date:            06/30/2016 – 08/15/2016

PV Types:            01; 08; 31; 52

 

As part of our “green” process, quarterly C-section rate letters are now available electronically, through the OHCA Provider Portal. Eliminating printing and postage for these correspondences are the agency’s best ways to reduce some of our administrative costs.

You may also view the release schedule on the OHCA webpage at www.okhca.org/c-section.

If you need help to retrieve your letters, please call 800-522-0114, option 2, for the Internet Helpdesk; choose option 1 for your questions concerning the Provider Portal.

6/22/2016 Ordering and Referring System Changes

Title:                     Ordering and Referring System Changes 

Run Date:            06/22/2016 – 08/05/2016 

Pv Types:             All 

 

 

Subject:  Ordering and Referring System Changes 

 

42 CFR § 455.440 requires that all claims for payment for items and services that were ordered or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered or referred such items or services.

In order to comply with this requirement:

·         The physician or other professional who ordered or referred the item or service must have an active SoonerCare contract.

·         The ordering or referring NPI on the claim must be for an individual, not for a group.

·         The ordering or referring provider must be of a specialty type that is eligible to order or refer.

In order to comply with the second bullet point, additional system edits went into effect on 6/16/2016.  After going into effect, more claims related to the referral edits denied than anticipated.  Therefore, in order to allow providers more time to prepare for this requirement, we have temporarily removed the referring NPI edits.  For easy reference, the common “referring” edits are:

4250 – Referring provider not contracted as individual

4259 – Referring not recipients PCP or not member of PCP group

4290 – Referring provider cannot be group provider

 

Edits for the ordering NPI remain active.  Any claims submitted without the individual ordering NPI will continue to deny.  Common “ordering” related edits are:

1136 – Ordering provider not eligible on date of service

1138 – Ordering provider is required for HCPCS/CPT code

 

We will be offering provider training focused on understanding and meeting these requirements.  A global message with more detailed training information will be posted soon.

If you have any questions, please contact Provider Services at 1-800-522-0114, option 1.

6/16/2016 Revised Caries Risk Assessment Form  

Title:      Revised Caries Risk Assessment Form

Run Date:   06/14/2016 – 08/01/2016

PV Types:   027

      Spc:  086, 271, 272, 273, 274, 275, 276, 277, 278
 

Global Message to all dental providers:

 OHCA has posted a revised Caries Risk Assessment Form on the OHCA public website Forms page: http://www.okhca.org/forms.  

 

More information regarding the Caries Risk Assessment may also be found on the Dental page of OHCA public website: http://www.okhca.org/dental-providers.  

6/14/2016 School Based IEP services change for ORDERING/REFERRING NPI  

Title:                School Based IEP services change for ORDERING/REFERRING NPI

Run Dates:      June 20, 2016 – July 31, 2016

PV Type:         12/120

 

Beginning June 20, 2016, contracted therapy companies submitting claims on behalf of OHCA contracted schools for IEP related services (for place of service 03 with a TM modifier) will no longer use the school’s NPI in the ordering/referring field.

As stated in Provider Letter 2013-44, this notice is in reference to 42 CFR 455.440, which states “that the State Medicaid agency requires the NPI of any ordering or referring physician or other professional to be specified on the claims for payment that is based on an order or referral of the physician or other professional”.  

6/13/2016 Physicians Contracts Expire 09/30/2016  

Title:       Physicians Contracts Expire 09/30/2016 

Run Date:    06/14/2016 – 10/01/2016 

PV Types:    All 

Physician contracts expire September 30, 2016, but the renewal process begins July 18. To avoid any delay in reimbursement, we encourage physicians to begin their renewals as soon as possible starting July 18.  

If you have any questions, please contact Provider Enrollment at 1-800-522-0114, option 5. 

6/13/2016 New Fee Schedule  

Title:       New Fee Schedule 

Run Date:    06/08/2016 – 07/31/2016 

PV Types:    All 

Remember that we update our fee schedule every July to rebase to the new Medicare RVUs. This update goes into effect on July 1 to match our state fiscal year.  The new fee schedule will be on our public website as soon as possible.  

Dates of service prior to July 1, 2016, are paid at last year’s rate and dates of service after July 1, 2016, are paid at the new rate.   

6/13/2016 Psychiatric Residential Treatment Facilities Attestation  

Subject:  Psychiatric Residential Treatment Facilities Attestation 

Run Dates:    06/15/2016 – 08/01/2016 

PV Types:     01 

Spc:          013, 015 

    

As required by OAC 317:30-5-95, Psychiatric Residential Treatment Facilities must submit an attestation statement to the Oklahoma Health Care Authority as part of their established provider agreement. 

Attestation statements are to be submitted annually and should be uploaded to the facility’s provider file through the Electronic Provider Enrollment System by the first of each fiscal year, July 1.  

 • Attestations must include the following information: 

  • Facility General Characteristics: name, address, telephone number of the facility, and provider identification number;
  • Facility Specific Characteristics:

 o   Bed size; 

 o   Number of individuals currently served within the PRTF who are provided service based on their eligibility for the Medicaid Inpatient Psychiatric Services for Individuals Under age 21 Benefit (Psych under 21); 

 o   Number of individuals, if any, whose Medicaid Inpatient Psychiatric Services Under 21 Benefit is paid for by any State other than Oklahoma; and 

 o   List all States from which the PRTF has ever received Medicaid payment for the provision of Psych under 21 services. 

  • The signature of the facility director;
  • The date the attestation was signed;
  • A statement certifying that the facility currently meets all of the requirements of Part 483, Subpart G governing the use of restraint and seclusion;
  • A statement acknowledging the right of the SA (or its agents) and, if necessary, CMS to conduct an onsite survey at any time to validate the facility’s compliance with the requirements of the rule, to investigate complaints lodged against the facility, or to investigate serious occurrences;
  • A statement that the facility will submit a new attestation of compliance annually and in the event a new facility director is appointed.
 
6/2/2016 Provider Payments Adjudicated the week of June 27, 2016  

Title:      Provider Payments Adjudicated the week of June 27, 2016

Run Dates:  June 1, 2016 – July 15, 2016

PV Types:   All

 

OHCA will delay payment for the claims adjudicated the week of June 27, 2016.  You will not receive a payment on June 29, 2016. The delayed payments will be made along with adjudicated claims incurred the following week on July 6, 2016.  Please make arrangements to accommodate this change.

6/1/2016 Change in limits for Psychotherapy Provided by Independent LBHPs  

Title:  Change in limits for Psychotherapy Provided by Independent LBHPs

Run Dates: 06/01/2016 – 07/15/2016

PV Types:  08, 53

   Spc:    193

 

Pursuant to emergency rules signed by the Governor found at 317:30-5-281, effective June 1, 2016, limits on psychotherapy provided by independent licensed behavioral health professionals (LBHPs) have changed. Psychotherapy is now limited to four (4) units/session per client per month.   

6/1/2016 Change in limits for psychotherapy and service plan updates provided by Outpatient Behavioral Health Agencies

Title: Change in limits for psychotherapy and service plan updates provided by Outpatient Behavioral Health Agencies

Run Dates: June 1, 2016 thru July 15, 2016

PV Types: 11

All Specialties

 

Pursuant to emergency rules signed by the Governor found at 317:30-5-241.2, effective June 1, 2016, limits on psychotherapy provided by outpatient behavioral health agencies have changed. Individual Therapy is now limited to four (4) units per day per client; family therapy is limited to 4 units per day per client; and group therapy is limited to six (6) units per day per client. Additionally, group therapy has a weekly limit of no more than three (3) hours per week per client. Individual and family therapy have a cumulative weekly limit of no more than 2 hours combined per week per client. Also effective June 1, 2016, service plan updates will only be reimbursable every six (6) months.

 5/13/2016  

Claims Submitted By Behavioral Health Licensure Candidates Are Now Processing Correctly

Claims Submitted By Behavioral Health Licensure Candidates Are Now Processing Correctly

Run Dates: May 13, 2016 through June 25, 2016

Provider Type 11

All Specialties

The systems error that was denying claims submitted by behavioral health licensure candidates has been fixed. If you have experienced denied claims for Licensure Candidates since 5/1/2016, you can now re-file your claims. We apologize for the inconvenience this issue has caused.


5/11/2016 Billing Error for Claims Submitted by Behavioral Health Licensure Candidates 

Billing Error for Claims Submitted by Behavioral Health Licensure Candidates

Run Date: 05/09/2016 – 06/22/2016

Provider Type 11

All Specialties

A systems error has been identified that is denying claims submitted on behalf of Behavioral Health Licensure Candidates for dates of service on and after 5/1/2016. We apologize for this inconvenience and are diligently working to address the error. Once the system is fixed, we will send a notice to providers so that denied claims can be resubmitted.

 
5/3/2016 Fee Schedule for Outpatient Behavioral Health Agencies

Fee Schedule for Outpatient Behavioral Health Agencies

Run Dates: May 2, 2016 through June 15, 2016

PV Types: 11

All Specialties

The fee schedule for outpatient behavioral health agencies has been updated and is effective 5/1/2016. The new fee schedule is located at www.okhca.org/behavioral-health. Dates of service prior to 5/1/2016 are paid at previous rates and dates of service after 5/1/2016 will be paid at the new rates.   

5/2/2016
New Fee Schedule for Independently Contracted Licensed Behavioral Professionals (LBHPs)

New Fee Schedule for Independently Contracted Licensed Behavioral Professionals (LBHPs)

Run Dates: April 29, 2016 through June 13, 2016

PV Types: 53 (LBHP) All Specialties

08 (clinics) 193 (Behavioral Health Group)

 

The fee schedule for independently contracted Licensed Behavioral Health Professionals (LBHPs) has been updated and will be effective 5/1/2016. The new independent LBHP fee schedule is located at www.okhca.org/behavioral-health<http://www.okhca.org/behavioral-health>. Dates of service prior to 5/1/2016 are paid at previous rates and dates of service after 5/1/2016 will be paid at the new rates.  

5/2/2016 New Fee Schedule for Independently Contracted Psychologists 

New Fee Schedule for Independently Contracted Psychologists

 Run Dates: April 29, 2016 through June 13, 2016

PV Type 11 Specialty 112

PV Type 53 Specialty 112

PV Type 08 Specialty 193

 

The fee schedule for independently contracted Psychologists has been updated and will be effective 5/1/2016. The new independent Psychologist fee schedule is located at www.okhca.org/behavioral-health<http://www.okhca.org/behavioral-health>. Dates of service prior to 5/1/2016 are paid at previous rates and dates of service after 5/1/2016 will be paid at the new rates.   

4/25/2016
Provider Letter 2016-05 

Title: Provider Letter 2016-05

 

PV Types:   27, 80, 84, 86

 

Provider letter 2016-05 serves to inform providers about newly activated dental codes and the caries risk assessment form. Please post all comments by close of business, Wednesday, May 15, 2016 via the policy change blog. Thank you for your participation in the process.   

4/18/2016
Access Monitoring Review Plan

Title: Access Monitoring Review Plan

 

Run Dates: April 18, 2016 through May 19, 2016

 

PV Types: All

 

CMS recently issued a final rule directing State Medicaid programs to analyze and monitor access to care for Medicaid Fee-for-Service programs. Through an access monitoring review plan, the State will demonstrate access to care by measuring the following: enrollee needs; the availability of care and providers; utilization of services; characteristics of the enrolled members, and estimated levels of provider payment from other payers. Please submit all comments by close of business, Thursday, May 19, 2016 via the policy change blog. Thank you for your participation in the process.  

4/4/2016
LBHP-Under Supervision Contracts 

Title:     LBHP-Under Supervision Contracts

PV Types:  53.536

Run Dates: March 31, 2016 thru May 31, 2016

Please NOTE: You cannot renew your existing contract as it is the LBHP specific contract. You must complete a NEW contract that is specific to the LBHP-Under Supervision provider type. This is a brand new Specialty Type.

The system is ready for you to complete your contracts today.

Please know that all LBHP-Under Supervision contracts must be completed by 5/31/2016.   

4/1/2016 Additional Information for Provider Letter 2016-07

Title: Additional Information for Provider Letter 2016-07

Run Dates: March 29, 2016 thru May 12, 2016

PV Types: All

This message is to provide additional information contained in provider letter 2016-07. We did not include the current visit limits we have established while we determine the utilization of this type of visit. For now, members will be allowed one visit per month with a maximum of 4 visits per year.  If a second visit is medically necessary in the same month, providers can request a prior authorization within 30 days from the date of service. If the prior authorization is approved, that visit counts against the yearly maximum.

Please call the OHCA call center if you have additional questions at 1-800-522-0114. 


3/28/2016
Provider Letter 2016-07

Title: Dear Provider Letter 2016-07

Run Dates: 3/28/16-5/11/16

PV Types:   031, 052, 072, 080, 081, 082, 088, 092, 093, 100, 184, 185

 

Provider letter 2016-07 serves to inform providers on codes associated with virtual visits. Please post all comments by close of business, Friday, April 28, 2016 via the policy change blog. Thank you for your participation in the process.

3/22/2016 DME Codes moved from Max Fee Method to Manual Pricing

Title: DME Codes moved from Max Fee Method to Manual Pricing

Run Dates: March 21, 2016 thru June 30, 2016

PV Types: 250 – DME/Medical Supply Dealers

Two codes have been moved from MAX fee items to Manually Priced items effective January 1, 2016.  Both codes will be processed as manually priced items.

A4627 – Spacer Bag Reservoir will be paid at the lesser of MSRP -30% or Cost + 30% (less the 3 % Budget Reduction effective January 1, 2016) – invoices and proof of delivery must be attached to the claim for payment consideration

E0638 – Standing Frame System will be paid at the lesser of MSRP -30% or Cost + 30% - the 3% reduction will not be applied to this code since it is classified as Complex Rehab  Technology– invoices and proof of delivery must be attached to the claim for payment consideration.

Contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org for additional clarification.    

3/16/2016
Provider Letter 2016-06

 

Title: Provider Letter 2016-06

 

Run Dates: 3/16/16-4/29/2016

PV Types:   02, 31, 80, 81, 82, 84, 90, 91, 92, 93, 100, 184, 185, 192, 195, 197, 199, 240, 316, 318, 319, 322, 329, 341, 344, 345, 355, 356, 359, 526, 540
 

Provider letter 2016-06 serves to inform providers on prior authorization for medications Neulasta, Granix, and Zarxio. Please post all comments by close of business, Friday, April 15, 2016 via the policy change blog. Thank you for your participation in the process. 

3/7/2016
Prior Authorizations  

TITLE: Prior Authorizations          

RUN DATE: 3/3/16 – 4/18/2016

PV Types:  All

Prior Authorizations (PAs) are reviewed based on medical necessity and must be submitted by providers who are contracted with SoonerCare.  42 CFR § 455.410 requires all ordering or referring physicians, or other professionals providing services under the State plan or under a waiver of the state plan, to be enrolled as a contracted provider with SoonerCare.  It will be the responsibility of the Servicing Provider to verify that each order received is from an ordering/referring SoonerCare provider prior to submitting for Prior Authorization.  Reminder, Prior Authorization is not a guarantee of payment.

If you have questions regarding the PA process, please contact the OHCA Call Center toll free at (800) 522-0114 or, in Oklahoma City, call (405) 522-6205. 

2/29/2016 Member Applications down for maintenance

Title: Member Applications down for maintenance

Run Dates: 2/29/16-4/15/2016

Provider Type 1 and 11

Provider Type 1: NODOS and eNBI application systems will be down for maintenance between 6 pm Friday March 4 – 8 am Monday March 7, 2016.

 

Provider Type 11:  ODMHSAS application system will be down for maintenance between 6 pm Friday March 4 – 8 am Monday March 7, 2016.  

2/22/2016 PPR Reports

TITLE:        PPR Reports

Run Dates:    02/19/2016 – 04/01/2016

PV Types:     01 – Hospitals

              010 – Acute Care

              011 – Psychiatric

              012 – Rehabilitation

              013 – Residential Treatment Center

              014 – Critical Access

              015 – Children’s Specialty

              016 – IHS Hospital

   

OHCA recently distributed by email Hospital Potential Preventable Readmissions (PPR) data for CY 2014 which is informational only. A summary document may have been attached and may show a penalty but it is to illustrate the methodology only, penalties will NOT be assessed related to the CY 2014 data. Soon, the CY 2014 data will be accessible on the provider portal. To access, follow these steps after you have logged into the Provider Portal:

 
  1. From the Provider’s My Home Page, select the Reports tab.
  2. Click on the link called Provider Reports.
  3. Select the Report name from the Report Title dropdown.
  4. Select the Report Year from the Report Year dropdown.
  5. Click Search.
 

OHCA will make CY 2015 Hospital PPR data available on the provider portal in April 2016. The penalty per hospital will vary and will be collected in the quarter ending June of 2016. Per diem facilities (Freestanding Psychiatric Hospitals, Psychiatric Residential Treatment Facilities, IHS/Tribal) are included in the analysis but excluded from penalties, so these facilities may receive informational only data related to the program, but penalties will NOT be assessed.   

2/18/2016
Lemtrada® (alemtuzumab) J0202

TITLE:    Lemtrada® (alemtuzumab) J0202

Run Date: 02/16/2016 – 04/01/2016

PV Types: All

 

Lemtrada® (alemtuzumab) requires a prior authorization when billed through a physician or outpatient claim via J code, J0202.  Lemtrada® is not available through the SoonerCare pharmacy benefit. The prior authorization criteria are below and can be found in the Central Nervous System section at www.okhca.org/pa.  

2/18/2016 High Risk Obstetrical Services CH-17 Form Update

Title:      High Risk Obstetrical Services CH-17 Form Update

Effective 02/09/2016

 

Run Date:   02/10/2016 – 04/30/2016

 

PV Types:   31 - Physician

091 - OB Nurse Practitioner

181 - Maternity

199 - OB/GYN Group

214 - High Risk Pregnant Women

316 - Family Practitioner

318 - General Practitioner

328 - Obstetrician/Gynecologist

335 - Maternal Fetal Medicine

564 - Primary Care Provider

 

Form CH-17 for High Risk Obstetrical Treatment Plan/Prior Authorization Request has been updated to allow modifiers for twins and triplets.

 

1.  Providers may request up to 3 units (combined) for 76815 + 76816 + 76817 for  

    each fetus.  Modifiers 26 & TC selected together per code count as 1 unit;

    circle/check 59 modifier for twins, 59 & 76 modifiers for triplets.

 

2.  Providers may request up to 5 units (combined) for 59025 + 76818 + 76819 for

    each fetus.  Modifiers 26 & TC selected together per code count as 1 unit;

    circle/check 59 modifier for twins, 59 & 76 modifiers for triplets.

 

For information regarding requirements and submission of a Prior Authorization request for High Risk Obstetrical services, please view the Medical Authorization Unit public webpage at www.okhca.org/mau, select High Risk OB (HROB)link. Also refer to OHCA policy 317:30-5-22.1 Enhanced services for medically high risk pregnancies [Revised 09-01-15]. Forms may be accessed on the OHCA public website at www.okhca.org under the Providers section.

 

If you have additional questions please call the OHCA Call Center Provider Helpline at (800)522-0114.      

2/17/2016 Modified Stage 2 Delay

Title:        Modified Stage 2 Delay

Run Dates:    02/16/2016 – 04/01/2016

PV Types:     31, 52, 09, 27, 10

 

Due to unforeseen circumstances, the Modified Stage 2 changes will not be available until March 3. We apologize for any inconvenience.

 

If you have any questions or need more information regarding the delay, please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org or visit our website: www.okhca.org/ehr-incentive.

 
2/12/2016 EHR Attestation – Go Live

TITLE:    EHR Attestation – Go Live

Run Date: 02/12/2016 – 04/01/2016

PV Types: 09 – Advance Practice Nurse

          10 – Mid-Level Practitioner

          27 – Dentist

          31 – Physician

          52 – State Employed Physicians

   

As the Oklahoma Health Care Authority is in the process of updating its EHR attestation system per the regulations outlined in the Modified Stage 2 final rule, we have developed a document to outline the changes. OHCA is working diligently to have these changes implemented as soon as possible. Our anticipated go live date is February 18, 2016.

 

For program year 2015 only, the attestation tail period will be extended through May 31, 2016. 

2/11/2016 Medicaid Dental Documentation Seminar

Title:    Medicaid Dental Documentation Seminar

Run Date: 02/11/2016 – 04/01/2016

PV Types: 27 Dentist

   Spc:   086 – Dental Clinic

          271 – General Dentistry Pract

          272 – Oral Surgeon

          273 – Orthodontist

          274 – Pediatric Dentist

 

The OHCA invites all dental providers to attend the Medicaid Dental Documentation Seminar that will be held in:

 

Tulsa, March 4 & 5;

OKC, March 18; and,

Lawton, March 19.  

 

This presentation will provide a framework for better understanding Medicaid requirements, SoonerCare policy and problem areas related to records and billing reviews.

 

Please register for these trainings at the link below

   

http://www.okhca.org/providers.aspx?id=110&parts=7557_7559  

2/09/2016 Board Agenda Change

TITLE:   BOARD AGENDA CHANGE

RUN DATES: 2/09/2016 - 3/23/2016 

PV Types:         08, spec 193

53 All Specialties

The proposed emergency rule identified as WF# 16-01 regarding reimbursement for Master’s prepared licensed behavioral health professionals in independent practice is being removed from the February 11 OHCA Board meeting agenda. Instead, the proposed rule will be presented as a permanent rule and will be presented at a public hearing April 1, 2016 at 9:00 a.m. followed by an OHCA Board meeting at 1:00 p.m. For more information on this and other proposed rules, visit www.okhca.org/policyblog.  

2/4/2016 Reminder of Federal Requirements

TITLE:      Reminder of Federal Requirements

RUN DATES:  02/04/2016 – 03/27/2016

PV Types:   All

 

REMINDER OF FEDERAL REQUIREMENTS FOR SUBMITTING CLAIMS FOR SERVICES PROVIDED TO SOONERCARE MEMBERS.

 

42 CFR § 455.410 requires all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the state plan to be enrolled as a contracted provider with SoonerCare.  In addition, 42 CFR § 455.440 further requires that all claims for payment for items and services that were ordered or referred to contain the National Provider Identifier (“NPI”) of the physician or other professional who ordered or referred such items or services.

 

We have modified our claims processing system accordingly.  As a result, effective immediately, claims filed electronically with OHCA will be denied unless the claim complies with these requirements.  

2/3/2016
Provider Letter 2016-04
  1. Title: Dear Provider Letter 2016-04

    PV Types:   09, 10, 31, 52, 80, 81, 82, 84, 184, 185, 195

    Provider letter 2016-04 serves to inform providers on prior authorizations for medications used to treat breast cancer. Please post all comments by close of business, March 4, 2016 via the policy change blog. Thank you for your participation in the process.
 
1/15/2016 OKDMHSAS Proposed Changes

Title:        OKDMHSAS Proposed Changes

RUN DATES:    01/15/2016 – 02/28/2016

PV TYPES:      ALL

 

On January 13, 2016 the Department of Mental Health and Substance Abuse Services notified the Oklahoma Health Care Authority and members of the Behavioral Health Advisory Council of the following proposed changes. Elimination of Private individual Licensed Behavioral Health Providers including those participating in a Behavioral Health Group. Additional information can be found at http://okhca.org/PolicyBlog.aspx. These changes are necessary to reduce the Agency’s spending to balance the state budget in accordance with Article 10, Section 23 of the Oklahoma Constitution, which prohibits a state agency from spending more money than is allocated.

1/11/2016 Follow-up to Provider Letter 2016-01

Title:    Follow-up to Provider Letter 2016-01

Run Date: 01/06/2016 – 02/21/2016

PV Types: All

 

Per Provider Letter 2016-01, with the implementation of HCPCS G0477-G0483, OHCA would not expect to see non-specific pathology/laboratory CPT codes billed in addition to the HCPCS codes for presumptive or definitive drug testing. These CPT codes include, but are not limited to: 80299, 82542, 83516, 83518, 83519, 83520, 83789, 84311 and 84999.  

 

If any of these CPT codes are billed as part of a service that is separate from presumptive or definitive drug testing, then documentation in the record should reflect the indication for ordering these tests. If these codes are paid along with the HCPCS codes noted above for drug testing alone, this is considered unbundling and is subject to recoupment.

 

HCPCS codes G0480 through G04383 are the only codes a provider should submit for reimbursement when performing definitive drug testing. Please refer to the definitive drug classes listing in CPT for further clarification.

1/5/2016
Provider Letter 2016-01

Title:        Dear Provider Letter 2016-01

Run Date:      01/05/2016 – 02/20/2016

PV Types:      01, 08, 09, 10, 11, 28, 31, 52

Provider letter 2016-01 serves to update providers on controlled substance monitoring and drugs of abuse testing. Please post all comments by close of business, February 4, 2016, via the policy change blog. Thank you for your participation in the process.

1/4/2016 NH Crossover Payments 

Title:       NH Crossover Payments

Run Date:    01/01/2016 – 02/20/2016

PV Type:     Nursing Homes:

             03-Extended Care Facility

030 Nursing Facility
031 ICF/MR &gt; 6 Beds
032 Pediatric Nursing Facility
033 Residential Care Facility
034 ICF/MR &lt; 6 Beds
035 Skilled Nursing Facility
036 Respite Care - Facility Based
037 Assisted Living
 

Effective January 1, 2016, the payment for Nursing Home Crossovers Part A, co-insurance and deductibles will be reduced from 75% to 20%.

 
12/17/2015 Contracts for LBHPs Under Supervision

TITLE:       Contracts for LBHPs Under Supervision

Run Date:    12/17/2015 – 02/05/2016

PV Types:    53 / 536

 

Current contracts for LBHPs Under Supervision have been extended through 05/31/2016. Please disregard renewal letters at this time. Thank you.

12/14/2015 Dental Prior Authorization

TITLE:       Dental Prior Authorization

Run Dates:   12/09/2015 – 01/31/2016

PV Types:    080,270,271,272,273,274,275,276,277

 

Effective 12/10/2015 Dental providers will be able to submit additional documents through the OHCA provider portal when the

status is “awaiting documents” or “pending documents”. This will provide a faster turnaround time, which will benefit SoonerCare members.  

11/30/2015
DMEPOS HCPCS CODE CHANGES EFFECTIVE 01/01/2016

Title:      DMEPOS HCPCS CODE CHANGES EFFECTIVE 01/01/2016

Run Date:   11/24/2015 – 01/31/2016

PV Types:   250 – DME/Medical Supply Dealers

OHCA and CMS have made the following changes to HCPCS codes effective with dates of service on or after January 1, 2016.

Deleted Codes:

A7011 –  Non-Disposable Corrugated Tubing

E0450 -  Volume Control Ventilator Invasive Interface *

E0460 –  Negative Pressure Ventilator Portable/Stationary **

E0461 -  Volume Control Ventilator Non-Invasive Interface**

E0463 -  Pressure Support Ventilator Invasive Interface *

E0464 –  Pressure Support Ventilator Non-Invasive Interface **

 

New Codes:

  • * Code replaced with NEW Code – E0465 – Home Ventilator, any type, used with invasive Interface – monthly continuous rental
  • ** Code replaced with NEW Code – E0466 – Home Ventilator, any type, used with non-invasive interface – monthly continuous rental
  • E1012 – Center Mount Power Elevating Leg Rest – Purchase only
 

Prior Authorization Ventilator Transition Instructions

 

Current PA’s in Process at MAU

 

Request submitted prior to December 31, 2015 that are Approved will be amended or processed by Medical Authorizations  Unit (MAU) as follows:

 
  • End date 2015 code effective 12/31/2015
  • Add the 2016 code to the PA with the end date remaining as the original requested end date.
  • Providers must review PA on file and bill with the corresponding HCPCS code for the appropriate date of service

Requests received January 1, 2016 or after must be submitted with correct code or request will be cancelled.

 

Contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org  or MAU at MAUADMIN@okhca.org if you have any questions about this change.

11/30/2015
Provider Letter 2015-27
Provider letter 2015-27 serves to inform providers of Prior Authorization of New 2016 Molecular Pathology Codes, effective January 1, 2016. Please submit all comments by close of business, Thursday, December 31, 2015 via the feedback form. Thank you for your participation in the process. 
11/30/2015
Provider Letter 2015-25
Provider letter 2015-25 serves to update providers on SoonerCare Choice Behavioral Health Screenings, effective January 1, 2016. Please submit all comments by close of business, Thursday, December 31, 2015 via the feedback form. Thank you for your participation in the process.
11/16/2015 Physicians Assistants Contracts

Title:            Physicians Assistants Contracts

Run Dates:        11/16/2015 – 02/07/2016

PV Types:         100 – Physician Assistants

   

Physician Assistants contracts expire January 31, 2016. In order to keep your participation in SoonerCare current, you can begin the renewal process now. Please access the provider enrollment page through our public web site at:

http://www.okhca.org/providers.aspx?id=105&menu=56&parts=7551_7553_7555

   

Please call us at 1-800-522-0114 Option 5 if you have any questions

11/16/2015 Special Process Claims Webinar – November 19, 2015

Title:    Special Process Claims Webinar – November 19, 2015

Run Dates:    11/16/2015 – 12/01/2015

PV Types:      All

 

OHCA and Hewlett Packard Enterprise will be offering a Special Process Claims Webinar Thursday, Nov. 19, at 2 p.m. Providers will learn when, why and how to send claims for special processing/manual review. Specific topics include 1500 Professional and UB-04 Institutional claim examples (including timely filing), HCA-17 and HCA-28 forms, Return to Provider letters, and claims that do not need to be sent for special processing. This webinar is recommended for all SoonerCare providers and billing staff who utilize the 1500 Professional or UB-04 Institutional claim forms.

Click here to register

11/6/2015
DME Prior Authorization Codes

OHCA has determined that the following codes will require Prior Authorization effective with dates of service on or after January 1, 2016.  The rental period will be limited to 13 months capped rental.

E0260 – Semi-Electric Bed with Rails & Mattress
E0910 – Trapeze Bar – attached to Bed
E1050 – Fully Reclining Wheelchair

The 30-day retro option will continue to apply to these and other DMEPOS items that require Prior Authorization.
If you have questions, please contact Stan Ruffner, DMEPOS Director at 405.522.7924.

11/2/2015 Documentation for Dental PAs & SC Compensable Radiographs

Title:        Documentation for Dental PAs & SC Compensable

              Radiographs

Run Dates:    10/27/2015 – 12/11/2015

PV Types:      27 – Dentist

              86 – Dental Clinic

     Spc:      271 – General Dentistry

              272 – Oral Surgeon

              273 – Orthodontist

              274 – Pediatric Dentist

 

OHCA has noticed a recent decline in the quality of radiographs & digital records submitted.  A friendly reminder:

Original film or digital images are acceptable. Poorly scanned paper copies of film are discouraged. Undiagnostic radiographs may result in delay and/or denial of prior authorization requests.  Per policy:

   

317:30-5-698. Services requiring prior authorization

[Revised 09-01-15]

(d)Minimum required records to be submitted with each request are right and left mounted bitewing x-rays or images and periapical films or images of tooth/teeth involved or the edentulous areas if not visible in the bitewings. X-rays must be submitted with film mounts and each film or print must be of diagnostic quality. X-rays and/or images must be identified by the tooth number and include date of exposure, member name, member ID, provider name, and provider ID. All x-rays or images, regardless of the media, must be submitted together with a completed and signed comprehensive treatment plan that details all needed treatment at the time of examination, and a completed current ADA form requesting all treatments requiring prior authorization. The film, digital media or printout must be of sufficient quality to clearly demonstrate for the reviewer, the pathology which is the basis for the authorization request. If radiographs are not taken, provider must include in narrative sufficient information to confirm diagnosis and treatment plan.

 

317:30-5-696 (D)Radiographs (x-rays)

To be SoonerCare compensable, x-rays must be of diagnostic quality and medically necessary.

   
10/30/2015 Dear Provider Letter 2015-24

TITLE:         Dear Provider Letter 2015-24

PV Types:      08, 09, 10, 14, 31, 52

Provider letter 2015-24 serves to inform providers of multiple procedure modifier usage and editing, effective December 1, 2015. Please submit all comments by close of business, November, 29, 2015 via the feedback form. Thank you for your participation in the process.

10/21/2015 Claims Adjudication Review Process

TITLE:         Claims Adjudication Review Process – Jean Krieske

Run Dates:    10/21/2015 – 12/11/2015

PV Types:      All

 

Due to the recent change in timely filing requirements, OHCA has noticed an influx of claims including re submissions.  Please be aware we are reviewing claims as quickly as possible and request that if claims have not been adjudicated to refrain from duplicate filing.

10/21/2015 EHR Upload Option

TITLE:        EHR Upload Option

Run Dates:    10/12/2015 – 12/01/2015

PV types:     31, 52, 09, 27, 10

   

EHR Incentive Team would like to announce a new way to submit documentation.

Most supporting documents currently being faxed in for EHR attestation can now be uploaded to the EHR acknowledgement page.  These documents include: vendor letter or documents supporting legal or financial obligation of a CEHRT, signature page, meaningful use reports, and other necessary documentation.  This does NOT include the patient volume report.  The patient volume report should still be emailed to EHRDocuments@okhca.org.

With the new upload option, you are able to submit up to four (4) files at one time.  All you have to do is select “Browse” attach your files, and then select “Upload”.  Please note that only the following file types are supported: .PDF, .PNG, .JPG, .JPEG, .BMP, .TIG, .TIFF, and .GIF.  If any of the documents to be uploaded is not one of the preceding file types, then it must be converted to an appropriate format.  Otherwise, it will not be received.

If you have any questions or need more information on the upload process, please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org or visit our website: www.okhca.org/ehr-incentive.

10/21/2015 Changes are coming

TITLE:         Changes are coming

Run Dates:    10/12/2015 – 12/01/2015

PV types:     31, 52, 09, 27, 10

   

With the recent announcement from Centers for Medicare and Medicaid Services the EHR Incentive Team would like to let you know we are in the process of reviewing the announced changes.  Some of the changes that we have been made aware of are: reporting times, fewer objectives to report on, Stage 3 requirements, and an effective date of the changes.

 

When the review has been completed the EHR Incentive Team will be putting out a newsletter and global message addressing the changes.

 

If you have any questions or would like more information, please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org or visit our website: www.okhca.org/ehr-incentive.

10/8/2015
Budget Outlook

Dear Provider,

 

Oklahoma’s budget and executive cabinet leadership has been meeting with state agency officials concerning the state fiscal year 2017 budget outlook. Leadership has advised that the budget outlook is grim. Agencies were requested to not submit any budget increases and to plan for potentially significant reductions.

This notice is to make you aware that the Oklahoma Health Care Authority (OHCA) may consider rate reductions for all SoonerCare providers as early as January 1, 2016. If reductions are inevitable, this will allow the cut to be smaller over the next 18 months rather than a deeper cut over a 12-month fiscal year.

More detail will be provided in November during the formal public notification process, and no final decision will be made before the OHCA board meets on December 10. Under these dire financial circumstances, it is important and prudent to advise you of this issue now. 

We have been advised not to expect any additional state funds to offset medical inflation or to offset more people qualifying for the program. Compounding the state budget outlook, the federal matching dollars will also decrease next year by more than $36 million, and we are waiting to hear the final cost of the state’s responsibility for Medicare A&B premium cost increases. Once we have this information, we will be able to project a proposed rate cut for January 1, 2016. 

Throughout the last two state fiscal years, we cut more than $280 million dollars (state and federal, combined) from our program and administrative budgets. In order to maintain federal funding for the program, the state is limited with regard to the budget areas that can be cut. Unfortunately, at this point, the majority of any budget reductions must be borne on the provider reimbursement fee schedule. 

We will keep you posted as there are further developments affecting our budget, and will keep the lines of communication open.  Please know that we are incredibly grateful for the quality services you provide to our SoonerCare members.  

Sincerely,

 

Nico Gomez 
Chief Executive Officer  

9/30/2015 Dear Provider Letter 2015-21

TITLE:       Dear Provider Letter 2015-21

Run Date:    09/28/2015 – 11/13/2015

PV Types:    01, 02, 08, 09, 10, 13, 16, 28, 31, 52

   

Provider letter 2015-21 serves to inform providers of changes molecular pathology prior authorization, effective November 1, 2015. Please submit all comments by close of business, Wednesday, October 28, 2015 via the feedback form. Thank you for your participation in the process. 

9/30/2015
Dear Provider Letter 2015-20

TITLE:       Dear Provider Letter 2015-20

Run Date:    09/28/2015 – 11/13/2015

PV SPC:      330, 543

 

Provider letter 2015-20 serves to inform providers of changes to vision codes V2782 & V2783, effective November 1, 2015. Please submit all comments by close of business, Wednesday, October 28, 2015 via the feedback form. Thank you for your participation in the process. 

9/29/2015
Updates to ESI Children’s Dental Processes  

Title:  Updates to ESI Children’s Dental Processes

Run Dates: 09/28/2015 – 10/30/2015

PV Types:  Dental: 27

SPC:  Dental: 086; 271, 272, 273, 274

Effective Oct. 5, 2015, dental providers will be able to access eligibility information and submit electronic claims for the Insure Oklahoma Employer-Sponsored Insurance (ESI) Children’s Dental program through the Oklahoma Health Care Authority’s online provider portal. Eligibility information will be noted under the term, “ESID.”

In addition, new program members will have an identification card that matches standard SoonerCare and Insure Oklahoma cards. Please remember to check eligibility through the provider portal before performing services. ESID provides dental coverage only; medical coverage is provided through a private insurance carrier.

9/28/2015 Provider Letter 2015-21

TITLE:   Dear Provider Letter 2015-21

Run Date: 09/28/2015 – 11/13/2015

PV Types: 01, 02, 08, 09, 10, 13, 16, 28, 31, 52


Provider letter 2015-21 serves to inform providers of changes molecular pathology prior authorization, effective November 1, 2015. Please submit all comments by close of business, Wednesday, October 28, 2015 via the feedback form. Thank you for your participation in the process.

9/28/2015 Provider Letter 2015-20

TITLE:   Dear Provider Letter 2015-20

Run Date: 09/28/2015 – 11/13/2015

PV SPC:  330, 543

Provider letter 2015-20 serves to inform providers of changes to vision codes V2782 & V2783, effective November 1, 2015. Please submit all comments by close of business, Wednesday, October 28, 2015 via the feedback form. Thank you for your participation in the process.

9/17/2015 Billing TPL, Non-HMO Claims

Title:       Billing TPL, Non-HMO Claims

Run Date:    09/17/2015 – 10/30/2015

PV Types:    All

 

When submitting all claims, the amount paid by a third party must be entered in the appropriate field on the claim form or electronic transaction.

If a third party payer made payment, an explanation of payment (EOP), explanation of benefits (EOB), or remittance advice (RA) is not required for electronically submitted claims.

When a member has other insurance and the primary insurer denies payment for any reason, a copy of the denial such as an EOP, EOB or RA must be attached to the OHCA claim or the claim will be denied.

If an EOP, EOB or RA cannot be obtained, attach to the claim a statement copy or correspondence from the third party carrier.

When billing the OHCA for the difference between the amount billed and the primary insurer's payment, the OHCA pays the provider the difference, up to the OHCA allowable charge. If the primary insurer payment is equal to or greater than the allowable charge, no payment is made by the OHCA. In this instance, the provider is not required to send the claim to the OHCA for processing. Providers cannot bill members for any balance.

For questions please call the OHCA Call Center at (800)522-0114, option 1.

   
9/15/2015
Rule Change 317:30-5-211.1 – Definition of “INVOICE” 

TITLE:      Rule Change 317:30-5-211.1 – Definition of “INVOICE”

RUN DATES:  09/15/2015 – 11/30/2015

PV TYPES:   DME – 250

Please see the revised definition for “Invoices” effective 9/1/15, that addresses exemption of invoice secondary discounts from the manual price calculation comparison of the lesser of MSRP – 30 percent or Cost + 30 percent. The previous definition required OHCA to apply any discount to that calculation.

317:30-5-211.1 Definitions [Revised 09-01-15]

 

"Invoice" means a document that provides the following information, when applicable: description of product; quantity; quantity in box; purchase price; NDC; strength; dosage; provider; seller's name and address; purchaser's name and address; and date of purchase. At times, visit notes will be required to determine how much of the supply was expended. When possible, the provider should identify the SoonerCare member receiving the equipment or supply on the invoice.

 

If you have questions, you may contact Stan Ruffner, DMEPOS program director, at 405-522-7924.    

 
9/14/2014 NDC Requirement on Medicare Part B Crossover

Claims and for Albumin Products


TITLE:         NDC Requirement on Medicare Part B Crossover

              Claims and for Albumin Products

RUN DATES:    09/11/2015 – 12/01/2015

PV TYPES:     All

   

Effective 11/1/2015, the OHCA will require providers to submit the NDC information on physician and outpatient claims for Albumin products. The codes affected are P9041, P9045, P9046, and P9047. If these codes change or others are added for albumin in the future, the claims will still need to include the NDC information. Please make sure the Albumin product’s NDC being used is reimbursable by SoonerCare. Specific NDC coverage may be checked on the secure provider portal.

 

Also, since 2007 all HCPCS codes which require NDC information on the claim need the NDC submitted even if the primary payer is not SoonerCare. For example, if the member has Medicare Part B as primary and SoonerCare as secondary, the NDC information for the HCPCS code must be submitted on the claim to Medicare. Medicare will then forward this information over to the OHCA. This allows us to collect all of the federal drug rebates from the drug manufacturers for which SoonerCare has paid for a drug in full or in part.

9/1/2015
Dental Prior Authorization Process

TITLE:     Dental Prior Authorization Process

RUN Dates: 09/01/2015 – 10/15/2015

PV Types: 27 – Dentist

     SPC: 086, 271, 272, 273, 274, 275, 276, 277, 278

   

Effective 9-1-2015, OHCA is streamlining our Dental Prior Authorization process.  

 

The mailing address for paper submissions of Dental Prior Authorization & additional information has changed to:

 

HP / Dental Authorization

P.O. Box 548804

Oklahoma City, OK  73154-8804

 

All New Dental Prior Authorization requests & additional information documents for Dental Prior Authorizations must contain the Dental Prior Authorization Attachment Coversheet, HCA-13D.  This is available on the OHCA public website www.okhca.org & the OHCA Provider Portal.

 

OHCA encourages orthodontic providers to list 2 lines of D8080 when submitting a request for Comprehensive orthodontic treatment via OHCA Provider Portal and all mail submissions.

 
8/31/2015 LADC/Mental Health Provider Type 

Title:        LADC/Mental Health Provider Type

Run Dates:    08/28/2015 – 10/13/2015

PV Types:      11; 53

    SPC:      586

 

Any Licensed Alcohol and Drug Counselor (LADC) who has been designated as an LADC/Mental Health by the Oklahoma State Board of Alcohol and Drug Counselors needs to update their SoonerCare provider contract to reflect the correct specialty type (Specialty 587).  You can do this on line by going to this address:  https://www.ohcaprovider.com/hcp/Default.aspx?alias=www.ohcaprovider.com/hcp/provider then log in with your user name and password and go to update provider file and update the specialty type. For questions, contact OHCA Provider Enrollment at (800) 522-0114, Option 5.  

8/31/2015 Third-Party Resources - Inpatient Behavioral Health

 

Title:    Third-Party Resources - Inpatient Behavioral Health

 

Run Date: 08/28/2015 – 10/15/2015

 

PF Type:  01 Hospital

 

Spc: 010 Acute Care

 

011 Psychiatric

 

013 Residential Treatment Center

 

015 Children’s Specialty

 

As the state Medicaid agency, the Oklahoma Health Care Authority (OHCA) is the payer of last resort, with few exceptions. In accordance with OAC 317:30-3-24, when other health coverage resources are available, those resources must first be utilized by a member prior to filing a SoonerCare claim. This includes coverage by health maintenance organizations (HMO), preferred provider organizations (PPO) and any other insuring arrangements which provide a member access to health care. Members must comply with all requirements of their primary insurance and SoonerCare in order to take advantage of both coverages. 

 

For more information, refer to Chapter 14 of the OHCA billing manual on our r website: www.okhca.org/billing-manual, or contact OHCA provider services at 800-522-0114 for onsite training.


 
8/31/2015
New Fee Schedule for Independent LBHPs

Title:    New Fee Schedule for Independent LBHPs

Run Date: 08/31/2015 – 09/30/2015

PV Types: 53 (LBHP)

08 (Clinics)

     SPC: 530 thru 536 (all specialties for PV Group 53)

193 (Behavioral Health Group)

The fee schedule for independently contracted Licensed Behavioral Health Professionals (LBHPs) has been updated and will be effective 9/1/2015. The new private LBHP fee schedule is located at www.okhca.org/behavioral-health.

Dates of service prior to September 1, 2015 are paid at last year’s rate and dates of service after September 1, 2015 are paid at the new rate. 

8/27/2015
Nursing Home Crossover Payments

Title:       Nursing Home Crossover Payments

Run Date:    08/26/2015 – 10/09/2015

PV Types:    03; SPC 30, 35 (Nursing Facilities)

 

Effective July 1, 2015, the payment for Nursing Home Crossovers, co-insurance and deductibles, has been reduced from 100% to 75%.

8/25/2015
Clarification Regarding Psych Testing for Children, Ages 0-3

Title:   Clarification Regarding Psych Testing for Children, Ages 0-3

Run Date:   08/26/2015 – 09/30/2015           

PV Type:    08, 11, 53

   Spec:   193

 

Clarification is needed regarding OHCA Provider Letter 2015-13 which stated that psychological testing cannot be provided to children ages 0-3. While testing for a child 0-3 is not reimbursable if provided by an LBHP, APRN, PA, LPC, LMFT, LBP, LCSW, or LADC, testing is reimbursable for a child 0-3 when provided by a licensed psychologist. Psychotherapy for this age group is only appropriate when needed to support and strengthen the caregiver-child relationship as a vehicle for restoring and protecting the child’s mental health; therefore, providers should only bill for family psychotherapy for children 0 - 3. Group/individual/interactive psychotherapy for this age group is not reimbursable.

 
8/24/2015 Dental Policy Changes Effective 09/01/2015  

Title:       Dental Policy Changes Effective 09/01/2015

Run Dates:   08/21/2015 – 10/02/2015

PV Types:    27 – Dentist

    SPC:     086, 271, 272, 273, 274, 275, 276, 277, 278

   

Please note: important changes to OHCA dental policy go into effect 9-1-2015, as referenced in provider letter OHCA 2015-17. These policy changes will be on the OHCA public website as of 9-1-2015. Be sure to review OHCA dental policy 317:30-5-696, 317:30-5-698, 317:30-5-699, 317:30-5-700, and 317:30-5-700.1.

8/24/2015 Notice to Licensed, Contracted Hospitals

ITLE:         Notice to Licensed, Contracted Hospitals

RUN DATES:    08/20/2015 – 10/02/2015

PV/SPC TYPES: 01; 010, 011, 012,014,016

 

The Oklahoma Health Care Authority (OHCA) has completed all necessary requirements to allow hospitals to begin the Presumptive Eligibility application process for the following potential members:

  • Pregnant women
  • Parent/caregiver relatives
  • Children under age 19
  • Those seeking family planning services, and
  • Former foster children, ages 18 - 26

Effective September 1, 2015, interested hospitals can contact Katie in the Provider Enrollment department at 800-522-0114, option 5. She will send you the necessary forms to amend your contract to enable you to apply.

If you have any questions before speaking with Katie, please call the OHCA Provider Helpline at the number listed above.


8/18/2015 2015 School-Based Training Schedule

Title:           2015 School-Based Training Schedule

Run Dates:       08/18/2015 – 10/02/2015

PV/Spc Types:    12 / 120

 

School-Based Training is scheduled for the following dates and times.

 

September 16, 2015 – Stillwater (10:00am to 12:00pm)

September 23, 2015 – Poteau (1:00pm to 3:00pm)

September 29, 2015 – McAlester (10:00am to 12:00pm)

October 1, 2015 –  OKC (10:00am to 12:00pm)

 

Register for the training through OHCA website at

http://www.okhca.org/schoolbased

8/4/2015 Coverage & Processing Change for Saline Bullets

Title:    Coverage & Processing Change for Saline Bullets

Run Date: 08/04/2015 – 10/31/2015

PV Types: 25; 250 – DME

 

After review, OHCA has reinstated coverage for the 3mL and 15mL Sterile 0.9% NaCl Solutions for Inhalation (Saline Bullets) effective 8/1/15. 

DME providers may use code A9999 (Miscellaneous DME Supply or accessory, not otherwise classified) which will require a Prior Authorization.  The manual pricing method will be used to price the items which will require a copy of the invoice and proof of delivery to be attached to the claim.  Claims will be paid at the lesser of MSRP – 30% or Cost + 30%.

These products will be considered for a Fair Market Value pricing evaluation after we receive 90 days history of claims.  Only the 3mL and 15mL vials will be accepted for this process. 

If you have questions, contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org or 405-522-7924.

7/27/2015 New Incontinence Supply Coverage for SoonerCare Members Ages 4-20

Title:    New Incontinence Supply Coverage for SoonerCare Members Ages 4-20

Run Dates:    07/27/2015 – 09/07/2015

PV TYPES:     All

 

Effective July 1, 2015, SoonerCare will pay for the incontinence supplies (diapers, pull-ons, underpads [disposable and reusable]  and wipes) for children ages 4 through 20.  These supplies must be medically necessary. 

People First Industries (PFI) will be the only SoonerCare provider of incontinence supplies for these members.

If you have eligible SOONERCARE members who require incontinence supplies, a Physician Order for Incontinence Supplies, also known as HCA-52 form, must  be completed showing evidence of medical necessity. The HCA-52 form is available for download at www.okhca.org/provider-forms.

Instructions for completing the HCA-52 Physician Order for Incontinence Supplies can be located on the web-page for the Medical Authorization Unit. [Click here.] 

Once complete, the HCA-52 should be faxed to PFI at 580-924-1925 or 844-845-1076 to request a prior authorization (PA) from the Oklahoma Health Care Authority (OHCA).  OHCA will then send members a letter to advise them if the prior authorization has been approved or denied.  If approved, People First Industries will contact the member to schedule delivery of their supplies.

Thank you for your continued service to Oklahoma’s SoonerCare members.  If you have any questions, please call the OHCA call center at (800) 522-0114, option 1 or People First Industries at (866) 895-9956.

7/23/2015 Equipment Converted from Purchase to Capped Rental

Title:    Equipment Converted from Purchase to Capped Rental

Effective 08/012015

Run Dates:    07/23/2015 – 09/30/2015

PV TYPES:     25 & 250 - DME

The following codes have been changed from Purchase only to Capped Rental effective 8/1/15.  Providers must use the LL modifier which indicates that rental is applied to a purchase price.

OHCA does retain ownership of the equipment.  (317:30-5-211.18 Ownership of durable medical equipment).

E1805 – Dynamic adjustable wrist extension/flexion device

E1810 – Dynamic adjustable knee extension/flexion device

E1825 – Dynamic adjustable finger extension/flexion device

These changes are compatible with CMS categories for capped rental

If you have questions, contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org or 405.522.7924.

7/20/2015 Viscosupplementation of the Knee  

Title:    Viscosupplementation of the Knee

Run Date: 07/15/2015 – 09/05/2015

PV Spc:   316 – Family Practice

          331 – Orthopedics

          525 – Pain Med

          557 – Sports Med

After further consideration, OHCA will resume coverage for viscosupplementation (Hyaluronic acid (HA) knee injections) effective August 1, 2015.  The injections will only be covered for members with radiological evidence of osteoarthritis of the knee, who have failed conservative treatment.

Covered services that will require prior authorization (PA) from the OHCA Medical Authorization Unit (MAU) include: 

·         J7321-Hyaluronan or derivative, Hyalgan or Supartz, given at weekly intervals for 5 weeks for a total of 5 injections;

·         J7323-Hyaluronan or derivative, Euflexxa, given at weekly intervals for 3 weeks for a total of 3 injections;

·         J7324-Hyaluronan or derivative, Orthovisc, given at weekly intervals for 3 weeks for a total of 3 injections;

·         J7325-Hyaluronan or derivative, Synvisc, given at weekly intervals for 3 weeks for a total of 3 injections;

·         J7325-Hyaluronan or derivative, Synvisc One, given as one intra-articular injection;

·         J7326-Hyaluronan or derivative, Gel-One, given as one intra-articular injection.

         

***Note J7327-Monovisc is not covered at this time.

 

Repeat treatment will also require PA. Retreatment may be considered for members who have responded to previous injections, as demonstrated by a significant improvement in pain and functional capacity as well as a reduction of NSAIDS or other analgesics or anti-inflammatory medication needed during the 3-month period following initial treatment.   

Related services that do not require PA include the following:

  • 20610-Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance;
  • 20611-Arthrocentesis, aspiration and/or injection, major joint or bursa; with ultrasound guidance, with permanent recording and reporting. 

For more information regarding the PA process, please visit the MAU web page at www.okhca.org/mau, or contact the MAU at 800-522-0114. 

7/13/2015 DME Supply Changes Effective 07/01/2015

TITLE:        DME Supply Changes Effective 07/01/2015

Run Date:      07/07/2015 – 09/30/2015

PV Types:      250 – DME/Medical Supply Dealers

 

The following codes have been classified as non-covered as of 7/1/15 for TXIX (Sooner Care Members and Insure/Oklahoma). 

A4216 - - - Sterile Water/Saline, 10 ML

A4217 - - - Sterile Water/Saline, 500 ML

A4218 - - - Sterile Saline or Water, Metered Dose Dispenser, 10 ML

 

A4927 - - - Gloves, non-sterile, per 100

A4930 - - - Gloves, sterile, per pair

Providers may bill members for non-covered supplies.

Contact Stan Ruffner, DMEPOS Director, at stan.ruffner@okhca.org if you have any questions about this change.

7/8/2015 High Risk Obstetrical Services Budget Reductions

Title:    High Risk Obstetrical Services Budget Reductions

Effective 07/01/2015

Run Date: 07/08/2015 – 08/20/2015

PV Type:  31 Physician
091 OB Nurse Practitioner
181 Maternity
199 OB/GYN Group
214 High Risk Pregnant  Women
316 Family Practitioner
318 General Practitioner
328 Obstetrician/Gynecologist
335 Maternal Fetal Medicine
564 Primary Care Provider

High Risk Obstetrical services will be amended pursuant to the OHCA budget reduction effective 7/1/2015.

This reduction will affect newly submitted prior authorizations (PAs) approved with dates of service beginning 7/1/2015. If you have requested more units than are allowed, units will be reduced to the maximum allowed if the PA request is approved.

The reductions effective 7/1/2015 are:

1.  Maximum of three combined total units are allowed for codes 76815, 76816, and 76817

2.  Maximum of five combined total units are allowed for codes 59025, 76818, and 76819

3.  For multiple gestation: 10 units combined may be approved for codes

59025, 76818, and 76819 for twins; 15 units for triplets, etc. You may request these units on the initial PA request using form CH-17; a separate PA is not required.

If you have additional questions please call the OHCA Call Center at

(800)522-0114. 

7/8/2015 Requests for use of Non-Invasive Ventilators (E0463 & E0464) in the setting of COPD

Title:   Requests for use of Non-Invasive Ventilators (E0463 & E0464) in the setting of COPD

PV Types:    25; 250 – DME;

             31 – Physicians;

100 – Physician Assistants

             09 – Advanced Practice Nurse;

093 – Advanced Registered Nurse Practitioner

 

Run Dates:   07/08/2015 – 08/24/2015

After extensive research and consultation, OHCA Medical Directors have determined that there is no evidentiary support for improved patient outcomes using the Non-Invasive Ventilator vs. BiPAP for COPD (DX 496) and Respiratory Failure secondary to COPD in the outpatient setting.

Prior Authorization requests for these products with the diagnosis of COPD will be cancelled. 

7/7/2015 Office Visits Billed with Joint Injections

TITLE:        Office Visits Billed with Joint Injections

Run Dates:    06/29/2015 – 08/21/2015

PV Types:     PV Specialties: 140 (Podiatrist),

311 (Anesthesiologist),

315 (Emergency Medicine Practitioner),

316 (Family Practice),

318 (General Practitioner),

319 (General Surgeon),

321 (Hand Surgeon),

322 (Internist),

326 (Neurologist),

331 (Orthopedic Surgeon),

336 (Physical Medicine and Rehab Practitioner),

345 (General Pediatrician),

525 (Pain Medicine),

544 (Pediatric Orthopedics),

548 (Pediatric Rheumatology),

555 (Rheumatology),

557 (Sports Medicine),

93 (Advanced Registered Nurse Practitioner), and

100 (Physician Assistant)

 

In order to be compliant with OAC 317:30-5-9 (b) (10), which states, “Payment is made for both an office visit and an injection of joints performed during the visit if the joint injection code does not have a global coverage designation”, OHCA cannot reimburse for the office visit performed in conjunction with a joint injection as the joint injection service codes all currently have a global coverage designation.

 

Please note this policy does not address joint aspirations. OHCA may allow payment for an office visit billed with modifier 25 when documentation supports both the level of service billed and that a significant, separately identifiable evaluation and management service was performed for a different medical problem by the same physician or other qualified health care professional on the same day as a medically necessary joint aspiration. 

 

OHCA is currently working to update policy and will further notify you when the rules process is completed.  

 

7/7/2015 CPAP & CPAP Supply Coverage Changes effective 07/01/2015

Title:    CPAP & CPAP Supply Coverage Changes effective 07/01/2015

Run Date: 06/29/2015 – 09/30/2015

PV Type:  DME – 250

 

On June 25, 2015, the OHCA Board voted to remove coverage for CPAP for adults (21 and over) effective July 1, 2015 as part of the budget balancing process.

As a result of this decision, any initial CPAP Prior Authorization request must include proof of delivery for a date of service prior to 7/1/2015. The 30-day retro rule still applies. 

Adult members who are currently in an approved rental period are not affected by this change.  DME suppliers must continue to provide a compliance report for those in the first 3 months of rental for MAU consideration of either a purchase option or continued rental. If the report demonstrates member is non-compliant with the trial period, any future coverage will not be approved. Members in approved rental months 4-13 can continue to be billed until the 13th month.

CPAP supplies for members will continue to follow the current guidelines. 

ALERT - - - Even though the Secure website may show that the CPAP is covered for ages 0-999 to allow for the grandfathering members, this coverage change for adults (21 and over) is in effect 7/1/15.  This age range will be changed in 2016 to show only ages 0-20, after all grandfathered members have completed their rental cycle.

Contact Stan Ruffner, DMEPOS Director at stan.ruffner@okhca.org if you have any questions about this change.

7/2/2015 Dental Prior Authorization Webinar

TITLE:       Dental Prior Authorization Webinar

Run Dates:   07/02/2015 – 07/13/2015

PV Types:    27 – Dentist

    SPC:     086, 271, 272, 273, 274, 275, 276, 277, 278

 

OHCA will present a Dental Prior Authorization Webinar on Thursday, July 9th, 2015 from 2:00PM – 4:00PM CDT.  The main purpose of this webinar is to give step-by-step instructions on how to submit Dental Prior Authorizations via Provider Portal.  The class is open to any dental provider.  Space is limited to 50 registrants.  Provider Portal submission of Dental PAs is quick, easy and saves on postage!  To register, go to: http://www.okhca.org/providers.aspx?id=110&parts=7557_7559.

6/24/2015 Mirena® and Liletta® Billing  

Title:        Mirena® and Liletta® Billing

Dates to run:  7/1/15-9/1/15

PV TYPES:     All

 

Effective 8/1/15, OHCA will require a change in the billing of the hormonal intrauterine device (IUD) Mirena®. Currently J7302, levonorgestrel-releasing intrauterine contraceptive system, 52 mg, describes both Mirena® and Liletta® products.  The billing modifier U6 will now need to be added to J7302 on claims for Mirena®. J7302, without the modifier, remains the billing code for Liletta®.  Claims billed for either product still require the appropriate NDC information.

The reimbursement rate for Mirena® will be $855.89, while the reimbursement rate for Liletta® will be $660. These rates are subject to change based on information OHCA gathers.

6/23/2015 Important Notice: New PA Authorization Form

TITLE:         Important Notice: New PA Authorization Form

Run Dates:    06/13/2015 – 08/07/2015

PV Type:      17 - Therapists

              12 - School Based Services

    SPC:      Occupational (171), Physical (170) & Speech (173)

 

NEW SOONERCARE THERAPY MANAGEMENT AUTHORIZATION FORM EFFECTIVE JUNE 15, 2015 WITH NEW REQUIREMENTS:

 

NEW Therapy Management Authorization Form for Occupational Therapy, Physical Therapy and Speech Therapy services delivered in outpatient and school settings will be required effective June 15, 2015 and the previous form will NOT be accepted. 

IMPORTANT CHANGES TO THE FORM (also applies to WEB submission):

-CPT code section: Units requested should be the total number of units per CPT code for the duration of care requested

-Specialty Therapy modifiers must be submitted (include additional modifiers as necessary):  Speech Therapy – GN; Occupational Therapy – GO; Physical Therapy - GP

 

-“TM” modifier must be included if services will be provided in a school setting

-Modifiers must be billed in the same sequential order as authorized to receive payment

-Duration of Care is required; Referring provider section: OHCA ID is not required

 

Failure to complete form in full will result in processing delays.

The instructional guide can be used as a resource in completing the form.  Please visit our website at http://www.triadhealthcareinc.com/soonercare to download the form and instructions.

 

If you have any questions regarding the new Therapy Management prior authorization form, please contact the Provider Engagement team at: providerengagement@medsolutions.com.

6/19/2015 HMO Claims Billing Now Available via SoonerCare Provider Portal

Title:       HMO Claims Billing Now Available via SoonerCare Provider Portal

Run Dates:   06/19/2015 – 08/05/2015

PV TYPES:    All

Effective 6/18/2015, providers will be able to submit HMO claims using the SoonerCare Provider Portal. Paper submission will no longer be required for these claims. These will be region 94 claims and must be billed for the copay amount (rather than billing for the total charges) and an EOB must be attached. When submitting a claim on the Provider Portal you will find a dropdown box labeled “HMO Copay”, this box will need to be changed to “yes” when billing the claim as an HMO.

6/16/2015 Behavioral Health Case Manager Certification Renewals

Title:  Behavioral Health Case Manager Certification Renewals

Run Dates:    06/16/2015 – 08/01/2015

PV TYPES:     PV 11

              SPC 110, 111, 114, 118, 123

All Behavioral Health Case Manager certifications must be renewed by June 30 through ODMHSAS. Once renewed, case managers must update their OHCA provider file with proof of renewal in order to continue to bill SoonerCare for services after June 30. For questions about certification renewals, contact Ramona Gregory at 405-522-5366. For SoonerCare contracting questions, contact Provider Enrollment at 1-800-522-0114, Option 5.

6/11/2015 New Fee Schedule

Title:       New Fee Schedule

Run Date:    06/11/2015 – 07/31/2015

PV Types:    All

Remember that we update our fee schedule every July to rebase to the new Medicare RVUs. The new fee schedule will be on our public website as soon as possible.

Dates of service prior to July 1, 2015 are paid at last year’s rate and dates of service after July 1, 2015 are paid at the new rate.
6/9/2015 DEN-2 Referral for Ortho Care    

Title:       DEN-2 Referral for Ortho Care

Run Dates:   06/09/2015 – 07/24/2015

PV Types:    271, 272, 273, 274, 275, 276, 277, 278

A friendly reminder to all dental providers:  Please use the current DEN-2 form when referring a member for comprehensive orthodontics. The DEN-2 Form can be accessed on the OHCA public website: http://www.okhca.org/providers.aspx?id=120

 

Older versions are no longer accepted.

5/18/2015 Provider Education Webinar/Conference Call regarding Cycle 1

Title:      Provider Education Webinar/Conference Call regarding Cycle 1

Payment Error Rate Measurement Reviews

Run Dates:  05/18/2015 – 07/22/2015

PV Types:   All

Oklahoma is beginning the Federal PERM (Payment Error Rate Measurement) cycle for SFY-2015.  State providers are invited to attend a Provider Education Webinar/Conference call to learn more about the program.  Information regarding the webinar can be found in the banner on the OHCA website.

What: Provider Education Webinar/Conference Calls regarding Cycle 1 Payment Error Rate Measurement Reviews by CMS

When: June 17, 2015, June 24, 2015, July 15, 2015, July 22, 2015.  Each Occurs at 2:00-3:00 pm CST.

Where: Webinar/Conference Call

How:  Provider Education Webinar/Conference Call Invitation can be found at www.cms.gov/PERM click on “Provider”, go to Downloads and click on “2015 Education Session Invitation (PDF.142KB)”.  The invitation provides the conference call numbers and webinar links.

For questions regarding the PERM CONFERENCE CALL, please email: James.Keethler@okhca.org.

5/5/2015 Testosterone Enanthate

Title:     Testosterone Enanthate

Run Date:  05/06/2015 – 06/15/2015

PV Types:  All

 

Effective May 15, 2015:

Testosterone enanthate injections will require a prior authorization whether billed through a physician/outpatient claim via J code, J3121,

or pharmacy claim via the appropriate NDC. 

The Pharmacy Help Desk, College of Pharmacy, is available to assist you: Toll Free: (800)522-0114; Oklahoma City Area: (405)522-6205; Option 6, 1.

The prior authorization criteria and tier chart can be found in the diabetes/endocrine section at www.okhca.org/pa.

4/14/2015 Change in Age Coverage for Silicone Trachestomy Tubes  

Title:    Change in Age Coverage for Silicone Trachestomy Tubes

Run Date: 04/14/2015 – 06/01/2015

PV Types: 25  – DME/Medical Supply Dealer

          250 – DME/Medical Supply Dealer

 

OHCA has determined that use of a silicone trachestomy (trach) tube has efficacy for a pediatric population.  Previously, OHCA allowed silicone trach use for ages 0-12.  Effective April 1, 2015, the age range has been changed to 0-20.

Providers are instructed to use the AU modifier when dispensing a silicone trach tube to children ages 0-20 to allow for the correct reimbursement rate.  Silicone trach tubes are limited to 3 per year without prior authorization.  If additional units are requested, medical necessity and prior authorization are required.

If you have questions, please contact Stan Ruffner, DMEPOS Program Director at 405.522.7924.

4/6/2015 ICD-10 Provider Testing

Title:        ICD-10 Provider Testing
 
Run Dates:    04/06/2015 – 05/21/2015
 
PV Types:    All
 
ICD-10 Provider Testing  
 
·    OHCA has completed beta testing along with Round 1 which ended on December 19, 2014 and Round 2 which will end on April 30, 2015.  There will be one last round in which a select number of Providers will have one final opportunity to conduct ICD-10 testing with the OHCA. This FINAL round of testing will run through the following time period:  
June 1, 2015 – August 28, 2015 
 
·    If you are interested in participating in this FINAL round of testing, you must send an email to the ICD10project@okhca.org no later than May 15, 2015.  Sending the email will not guarantee your inclusion in this final round of testing, but it does increase the probability that you would be selected. The email should include a subject heading of: “Requesting to Test ICD-10” and the body of the email MUST contain contact information for the person responsible for submitting your claims in Production today. For example, if you use a billing agent or clearinghouse to submit your claims, the contact information in the body of the email should be for that billing agent or clearinghouse. In addition to those who submit a request for testing to the ICD-10 mailbox, OHCA will use the same approach as used in Rounds 1 and 2 and select a defined set of billing agents and clearinghouses for testing. For the selected billing agents and clearinghouses, OHCA will request that the billing agents and clearinghouses define which providers they will submit claims for. Knowing which providers is critical to get things set up correctly in the test environment. Each billing agent or clearinghouse will be allowed to select no more than two of the providers for which they submit claims for in production today. 
 
·    It’s recommended that providers contact their billing agent or clearinghouse ASAP to let them know whether you’re interested in participating in testing, and to see if they’re capable and willing to submit your test claims if they’re contacted by HP to participate in the testing.  
 
·    Due to the effort involved to set up a billing agent, clearinghouse, and provider information in the test environment prior to the submission of test claims, testing must be limited in number.  In the past, testing was limited to approximately 10 to 20 billing agents and clearing houses per round of testing.  However, in order to expand the testing effort in this final round, that number will be increased to 20-30 billing agents and clearing houses. This will allow for approximately 40-60 providers to have their test claims submitted for ICD-10 testing.  The sooner we are contacted by interested parties, the better we will be able to manage the additional workload to feasibly accommodate the greatest number of providers.

 
4/6/2015 CMS Federal Requirements for Ordering and Referring

Title:         CMS Federal Requirements for Ordering and Referring

Run Dates:    04/01/2015 – 05/15/2015

PV Types:      All

 

As we continue to work with the Centers for Medicare & Medicaid Services (CMS) on the implementation of the federal requirements for ordering and referring, we have discovered the following system changes need to happen for claims to process correctly.

 

1.  The attending National Provider Identifier (NPI) must be on the inpatient UB claim.

2. The referring/ordering NPI must be included on Medicare crossover claims.

3. The referring/ordering NPI must be listed on outpatient UB claims.

4. The NPI submitted on these claims as the attending, referring or ordering must be the individual providers NPI, not an organization’s NPI.

 

The system will match the NPI on these claims. When it does not match the NPI on the individual’s contract file, the claim will deny.

4/1/2015 Urine Specimen Coding

Title:       Urine Specimen Coding

Run Date:    04/01/2015 – 05/15/2015

PV Types:    31, 52, 10, 09, 08

 

Providers - please be aware when obtaining a urine specimen with a straight catheter for UA or culture, the correct code to submit is P9612, ‘catheterization for collection of specimen, single patient, all places of service’. Additional payment is allowed for this service when billed with an evaluation and management procedure code.  CPT 51701, ‘Insertion of non-indwelling catheter, straight catheterization for residual urine’ is not the code to submit when obtaining a straight catheter urine specimen for UA or culture.  Evaluation and management services submitted for this code will be denied unless a significantly separately identifiable service is performed.

3/23/2015 Spinal Surgery

  Title:      Spinal Surgery

Run Date:   03/17/2015 – 04/30/2015

PV Types:   31 – Physicians

            01 – Hospital

            02 – Surgery Centers

            52 – Academic Physicians

      Spc:  331, Orthopedic Surgeons; 319, General Surgeon

342, Thoracic Surgeon; 325, Neurological Surgeon;

            544, Pediatric Orthopedics; 551, Pediatric Surgery (Neurology);

            559, Surgery Head & Neck; 010, Acute Care; 015 Children’s Spec

 

OHCA is suspending the requirement for inpatient facilities to obtain a prior authorization request (PAR) for spinal fusion and/or discectomy procedures. This change will be effective for surgeries performed on or after 3/1/2015.

However, the surgeon, co-surgeon or assistant surgeon will continue to require PAR for spinal fusions and/or discectomy procedures regardless of the place of service. 

In keeping with our current process, surgeons are required to submit the PAR, which must include the units and modifiers for both the outpatient facilities as well as the name of any surgeon who will need to file a claim. The PAR must include clinical documentation to support the medical necessity of the requested services.

The following CPT codes require PA:

22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22899, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63075, 63076, 63077, 63078.

For more information regarding the PA process, please refer to Provider Letter OHCA 2014-65, visit the “Spinal Fusion Surgery PA Overview” on our MAU webpage (https://okhca.org/providers.aspx?id-14674), or contact the MAU at 800-522-0114.

3/17/2015 2015 Spring Provider Training Workshop

Title:      2015 Spring Provider Training Workshop

Run Date:   03/16/2015-05/29/2015

PF Type:    All

 

PLEASE JOIN US FOR THE 2015 SPRING PROVIDER TRAINING WORKSHOP!

You and your staff are invited to attend the Spring 2015 SoonerCare Provider Training Workshops hosted by the Oklahoma Health Care Authority (OHCA) and HP Enterprise Services.

   

Classes include:

Dos, Don’ts and Did You Knows of Oklahoma SoonerCare; Navigating the OHCA Public Website; Understanding and Correcting Claim Denials; Electronic Referrals; DMEPOS Pricing, Policy and Process Changes; Patient-Centered Medical Home Compliance Review Updates; 1915(c) and Living Choice Updates; Medication Policy Updates; and Tobacco Cessation.

OHCA and HP highly recommend that all providers attend this workshop!

Class descriptions will explain the covered topics and recommended audience. Classes will fill up soon, so mark your calendar and register now!

 

Register today! Information and registration is available at: 

http://www.okhca.org/register 

http://www.okhca.org/classes

   

Durant, OK will be the first stop on April 23 followed by: Enid, April 30; OKC, May 13-14; and end in Tulsa, May 27–28.

3/11/2015 School-Based Training Schedule

Title:       School-Based Training Schedule

Run Dates:   03/11/2015 – 05/15/2015

PV Types:    120; 12

School-Based Training is scheduled for the following dates and times.

 

May 07, 2015 – Oklahoma City (10:00am to 12:00pm)

May 11, 2015 – Stillwater (10:00 am to 12:00pm)

May 13, 2015 – Poteau (1:00pm to 3:00pm)

May 14, 2015 – McAlester (10:00am to 12:00pm)

 

Register for the training through OHCA website at

http://www.okhca.org/schoolbased

3/11/2015 Diabetic Supply Process Change

Title:        Diabetic Supply Process Changes

Run Dates:    03/05/2015 – 07/05/2015

PV Types:     All

 

This message replaces Global Message/Banner Message #715: “Diabetic Supply Process Changes” posted effective 03/11/2015.

 

Beginning April 1, 2015 SoonerCare members will be able to obtain their glucometers, blood glucose testing strips, lancets, control solution, syringes and pen needles through their pharmacy provider.

There will be a 2 month transition period from the DME program to the pharmacy program. After May 31, 2015 SoonerCare members will be able to get these supplies through a pharmacy only.

There will be three (3) preferred glucometers and corresponding test strips available to our SoonerCare population which are One Touch, Free Style, and Precision.

For further information please visit our diabetic supplies webpage at www.okhca.org/bgsupplies
3/5/2015 LTC Print Options  Title:        LTC Print Options

 Run Dates:    03/06/2015 – 04/16/2015

PV Types: 03;       SPC: 30-35

A standard print option is now available for both the view and edit versions of your long term care cost reports. This option allows you to print all schedules or individual schedules. 

3/2/2015 Urine Drug Testing

Title:       Urine Drug Testing

Run Date:    02/18/2015 – 04/01/2015

PV Types:    All

 

As a reminder, when performing urine drug testing, OHCA letter 2014-36 advised providers specimen validity testing (SVT) is considered a quality control measure and coverage is excluded.  The NCCI Manual supports this.  Providers should not bill for SVT to confirm a urine specimen is not adulterated. SVT includes the following:

-pH

-specific gravity

-creatinine

-nitrates

-oxidants

-urinalysis

2/9/2015 DME Webinar  

Title:       DME Webinar

Run Dates:   02/09/2015-02/27/2015

PV Types:    25; 250

 

OHCA and HPES will be hosting a Durable Medical Equipment (DME) Webinar on Thursday Feb. 26th at 2:00pm. This webinar will cover Fair Market Value/Pricing Changes, Repair Changes (prior authorization and modifiers), and Oxygen. This webinar is recommended for all SoonerCare DME providers/owners, billing and prior authorization submission staff. 

Click here to register.
1/26/2015 Electroconvulsive Therapy Services

Title:        Electroconvulsive Therapy Services

Run Dates:    01/26/2015 – 03/13/2015

PV TYPES:     ALL

Effective 1/26/2015, Electroconvulsive Therapy services (CPT 90870) will require prior authorization. Providers should fax ECT therapy requests and all supporting documentation to (405) 530-7260. Please note, ECT requests will only be processed during business hours. For more information regarding this process, please direct questions to the Behavioral Health Unit at (405) 522-7597.
1/21/2015 Behavioral Health Transitional Targeted Case Management  

Title:    Behavioral Health Transitional Targeted Case Management

Run Date: 01/21/2015 – 02/28/2015

PV Types: 11

   Spc:   110, 111, 114, 118

 

Behavioral Health Transitional Targeted Case Management is now reimbursable for children transitioning from institutions to the community during the last 30 consecutive days of a SoonerCare covered institutional stay. For billing and prior authorization requirements, please visit www.odmhsas.org/arc.htm or contact the PICIS helpdesk at 405-521-6444 or gethelp@odmhsas.org.

1/21/2015 Nexplanon

Title:       Nexplanon

Run Date:    01/21/2015 – 02/28/2015

PV Types:    All

 

Effective 2/1/2015:

Nexplanon® will NO LONGER be available through the SoonerCare pharmacy benefit. Nexplanon® will only be covered as a medical benefit. The physician or facility will need to purchase the product. Once the Nexplanon® has been implanted then the provider can bill SoonerCare for the product.

1/21/2015 Rho(D) Immune Globulin Products

Title:    Rho(D) Immune Globulin Products

Run Date: 01/21/2015 – 02/28/2015

PV Types: All

Global Message for Rho (D) immune globulin Products

Effective 2/1/2015: The CPT codes 90384, 90385, and 90386 will NO LONGER be covered by SoonerCare. These products should be billed using the appropriate HCPCS codes. The NDC information is required when filing the claim using the HCPCS codes. For more information on How To Use An NDC When Billing Physician Administered Drugs please go to the Billing & Procedure Manual webpage on our website (www.okhca.org).

1/13/2015 WEBINAR - Introduction to Oklahoma SoonerCare Webinar

Title:    WEBINAR - Introduction to Oklahoma SoonerCare Webinar

Run Date: 01/13/2015 – 01/23/2015

PV Types: All  

OHCA and HPES invite new billing agents, clerks and providers to attend an Introduction to Oklahoma SoonerCare webinar on January 22nd at 2:30 p.m. The Introduction to Oklahoma SoonerCare webinar will cover billing and procedural aspects of Oklahoma SoonerCare. This training is not limited to specific provider types, yet serves as a general overview of all aspects of the Oklahoma SoonerCare program. Topics discussed will include covered services for adults and children, exclusions, additional programs supported by OHCA and general policy information. This webinar is recommended for all billing agents and billing clerks new to Oklahoma SoonerCare. 

Click here to register. 

1/12/2015 ICD-10 External Provider Testing (Follow-up)

Title:         ICD-10 External Provider Testing (Follow-up)

Run Dates:    01/12/2015 – 02/20/2015

PV Types:      All

 

RE:   ICD-10 Testing (Follow-up to previous Global Message: OHCA External

  Provider Testing Update)

  • OHCA completed a beta round of external provider testing on August 29, 2014 and will complete the first formal round (i.e., Round 1) of testing on December 19, 2014. Currently, two additional rounds of testing are scheduled as follows:
    • Round 2: February 2, 2015 – April 30, 2015
    • Round 3: June 1, 2015 – August 28, 2015
  • To facilitate the next round of testing, OHCA will use the same approach as that used for Round 1 and reach out to specific billing agents and clearing houses to define which providers will be selected to participate in the next round of testing. Each billing agent or clearing house will be allowed to select no more than two of the providers for which they submit claims for in production today.
  • It’s recommended that providers contact their billing agent or clearing house ASAP to let them know whether you’re interested in participating in testing, and to see if they’re capable and willing to submit your test claims if they’re contacted by HP to participate in the testing.
  • Due to the effort involved to set up the billing agent or clearing house and provider information in the test environment prior to the submission of test claims, testing must be limited to approximately 10 to 20 billing agents or clearing house per round of testing. This means that each round of testing could encompass a total of 20 to 40 providers.
  •  
 
1/8/2015 Influenza Vaccines

Title:    Influenza Vaccines

Run Date: 01/08/2015 – 02/20/2015

PV Types: All

 

Effective for DOS 1/1/2015, billing for Influenza vaccines is as follows:

Medicare claims for Influenze vaccine are submitted with the following HCPCS codes:

-          Q2035 Afluria

-          Q2036 Flulaval

-          Q2037 Fluvirin

-          Q2038 Fluzone

-          Q2039 Influenza vaccine NOS

All non-Medicare claims for Influenza vaccine are submitted with the following CPT codes, based on the vaccine and definition:  90654-90658, 90661, 90652, 90672, 90673, 90685-90688.

Influenza vaccines furnished by the OSDH in the VFC program for the 2014-2015 Influenza season can be located at this link.

http://www.ok.gov/health/Disease,_Prevention,_Preparedness/Immunizations/Vaccines_for_Children_Program/