2016 Global Messages

12/15/2016  Coding and Reporting Changes to the SoonerCare Choice Behavioral Health Screening 

Title:            Coding and Reporting Changes to the SoonerCare Choice Behavioral Health Screening 

Providers:     All 

Run Dates:   12/15/2016 – 02/01/2017 

  

Effective January 1, 2017, Current Procedural Terminology (CPT) 96160 (Administration and interpretation of patient-focused health risk assessment) will replace 99420 (Administration and interpretation of health risk assessment). This change is necessary due to the new American Medical Association (AMA) codes and guideline revisions being implemented for 2017.      

For full details regarding this change, please refer to Provider Letter OHCA 2016-31 which can be found at www.okhca.org/providerletters.    

If you have any questions, please call the OHCA call center at 1-800-522-0114. 

12/7/2016 New Electronic Submission Requirements for Medicare Crossover Claims 

Title:        New Electronic Submission Requirements for Medicare Crossover Claims 

Run Date:     12/05/2016 – 01/20/2017 

Provider Type: All   
  

Effective February 1, 2017, the Oklahoma Health Care Authority (OHCA) will require all Medicare crossover claims to be submitted electronically and in accordance with 42 CFR 424.32.

If you are experiencing any issues with your claims crossing over to OHCA electronically, verify that your provider numbers and any Medicare numbers are correct on our files to ensure your claims will process correctly.   

If you need assistance with submitting your Medicare crossover claims electronically, please call the SoonerCare Helpline at (800) 522-0114.  

Thank you. 

10/19/2016 SoonerHealth+ Update  

 TITLE:       SoonerHealth+ Update 

RUN DATE:    10/19/2016 – 12/02/2016 

Pv Type:     All 

 

 The Oklahoma Health Care Authority (OHCA) is exploring ways to improve health care services for SoonerCare’s Aged, Blind and Disabled (ABD) populations. During the 2015 legislative session, House Bill 1566 was passed which directed the OHCA to develop a request for proposal (RFP) for a care coordination model for this population. The agency selected a fully capitated, state-wide model of care coordination and named the initiative SoonerHealth+.

Although OHCA has not yet released the RFP or awarded any contracts, some health care companies may already be contacting you to determine if you would be interested in contracting with them. You are in no way obligated to do so.  However, if the RFP is awarded, the selected health care companies must have a provider network in place in order to serve ABD enrolled members.

The OHCA is currently developing the RFP and expects it to be released in November. Based on our current timeline, if the RFP is awarded, beginning in spring of 2018, SoonerCare ABD members that you serve will be enrolled in a managed care organization (MCO), which will be responsible for their health care needs. At that time, to continue to serve those ABD members, you would need to be contracted with the MCO selected.  However, until the RFP is awarded, the OHCA is not working with or endorsing any health care company seeking to be the chosen MCO.

More information on SoonerHealth+ is available on our website. OHCA will provide additional details on SoonerHealth+ as they become available.

10/19/2016 Long Term Care Cost Reports SFY16  

TITLE:    Long Term Care Cost Reports SFY16 

Run Date: 10/19/2016 – 11/05/2016 

PV Type:  03/30, 31, 32, 33, 34, 35 

  

Long Term Care Provider Cost Reports for SFY16 are due by 10/31/16. If the cost reports are not received in a timely manner, the facilities may be subject to a rate reduction equal to the amount of the direct care portion of the daily rate ranging $14.90 to $30.68 per patient day. 

10/19/2016 Additional Training Opportunities:Prior Authorization Required Process Change  

TITLE:    Additional Training Opportunities:Prior Authorization Required Process Change 

PV TYPES:  ALL 

Run Dates: 10/19/2016 – 11/15/2016 

Effective November 1, 2016, the Medical Authorization Unit (MAU) of the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) requests to be initiated electronically through the SoonerCare Provider Portal. For full details regarding this change, please refer to Provider Letter OHCA 2016-29 which can be found at: www.okhca.org/providerletters

Due to the high demand of our previous webinar on this topic, the Oklahoma Health Care Authority (OHCA) is offering additional training to help providers understand and meet these requirements. Webinars are scheduled for October 26, 2016, at 2 p.m. and November 10, 2016, at 2 p.m. 

OHCA recommends this presentation for all providers who submit or will begin submitting PA’s through the SoonerCare Provider Portal after November 1, 2016. This change does not include dental, pharmacy or behavioral health PAs. We will also address your questions at that time. 

Please register at http://okhca.org/provider-training.   

Thank you. 

10/5/2016 Training Opportunity: Prior Authorization Required  

TITLE:    Training Opportunity: Prior Authorization Required Process Change 

PV TYPES:  ALL 

Run Dates: 10/05/2016 – 11/01/2016 

Effective November 1, 2016, the Medical Authorization Unit (MAU) of the Oklahoma Health Care Authority (OHCA) will require prior authorization (PA) requests to be initiated electronically through the SoonerCare Provider Portal. For full details regarding this change, please refer to Provider Letter OHCA 2016-29 which can be found at: www.okhca.org/providerletters

We are offering a webinar that will focus on helping providers understand and prepare for this change. The webinar will be on October 18, 2016, at 2 p.m.   

OHCA recommends this presentation for all providers who submit or will begin submitting PA’s through the SoonerCare Provider Portal after November 1, 2016. This change does not include dental, pharmacy or behavioral health PAs. We will also address your questions at that time. 

Please register at http://okhca.org/provider-training.   

Thank you. 

9/29/2016 Effective November 1, 2016: Prior Authorization Required Process Change

TITLE:        Effective November 1, 2016: Prior Authorization Required Process Change 

Run Dates:    09/30/2016 – 11/15/2016 

PV TYPES:     ALL       

This global is to inform providers that effective November 1, 2016 the Oklahoma Health Care Authority (OHCA) Medical Authorization Unit (MAU) will require prior authorization (PA) requests to be initiated electronically through the SoonerCare Provider Portal.  After initiation of the PA request, providers may submit the necessary clinical records, photos and supporting documentation electronically. The OHCA prefers all documentation to be uploaded electronically, but will continue to accept documentation by fax or mail through June 30, 2017.  However, by July 1, 2017, OHCA intends to transition to an electronic PA submission process inclusive of documentation consistent with OHCA’s commitment to going “green” and reducing costs.  OHCA will provide additional information as this process progresses.    

This November 1, 2016 transition for PA requests to be initiated electronically through the SoonerCare Provider Portal will now include the following five areas: Spine Procedures, Joint Procedures, Cardiology Procedures, Pain Management and Radiation Therapy.     

Please note that this November 1, 2016, transition does not include dental, pharmacy or behavioral health PAs.    

A provider letter outlining this change and providing additional information will be sent soon and will also be found at: www.okhca.org/providerletters.  Please consider signing up for “WebAlerts” on this page to be notified when this and other new Provider Letters are posted.     

We will also be offering provider training to help prepare for this change.  A global message with more detailed information about the training will also be posted soon.    

If you need assistance with reviewing your prior authorizations online or submitting your clinical documentation or prior authorizations electronically, please call the SoonerCare Helpline at (800) 522-0114. Thank you for your continued support of our SoonerCare program.  

9/29/2016 C-Section Rates Letters  

TITLE:       C-Section Rates Letters  

Run Dates:   09/29/2016 – 11/11/2016 

PV Types:    01; 08; 31; 52 

  

The year-end C-section rates are now available electronically, through the OHCA Provider Portal letters. 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.     

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

Thank you. 

9/13/2016 Training Opportunity: Urine Drug Testing and Prior Authorization Requirements  

TITLE:        Training Opportunity: Urine Drug Testing and Prior Authorization Requirements 

RUN DATES:    09/13/2016 – 09/28/2016 

PV TYPES:     All    

  

The Oklahoma Health Care Authority (OHCA) revised urine drug screening and testing policy OAC 317:30-5-20.1 to update terminology of “presumptive” and “definitive” drug testing to mirror CPT/HCPCS coding reference manuals. Prior authorization (PA) for definitive drug testing went into effect March 1, 2016.     

Providers have verbalized confusion on the documentation required for the PA process. This webinar is to help providers understand the differences between presumptive and definitive drug testing and what documentation is required for the PA process. We will also show providers where the requirements and forms are located on the OHCA website. 

This webinar will be on September 27 at 2 p.m. OHCA recommends this presentation for all providers who provide, order and bill for urine drug testing services. We will also address your questions at that time.

Please register at http://okhca.org/provider-training.    

Thank you. 

9/7/2016 Last Day of Prior Authorizations Change (Psychiatric Residential Treatment Facilities) Training Opportunity

Title: Last Day of Prior Authorizations Change (Psychiatric Residential Treatment Facilities) Training Opportunity

Run Dates: 9/7/16-10/21/2016

PV: 01 013 015

Effective October 3, 2016, the Behavioral Health Unit of the Oklahoma Health Care Authority will implement a change regarding the last day of prior authorizations for Psychiatric Residential Treatment Facilities. Presently, the last day of a prior authorization includes a billable unit for that day; however, beginning October 3, 2016, the last day will no longer be billable. This change will assist providers with correctly submitting claims that reflect when the member was discharged from care.   

We are offering a webinar to help providers understand and prepare for this change. The webinar will be on September 15 at 2 p.m. OHCA recommends this presentation for EDI vendors, billers and utilization review personnel.   

Time will be given to address your questions.

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

9/1/2016 Suspending Coverage of Live Attenuated Influenza Vaccine Title: Suspending Coverage of Live Attenuated Influenza Vaccine

Run Dates: 9/1/16-11/14/2016 

PV: ALL 

The Oklahoma Health Care Authority allows immunizations as per the CDC’s Advisory Committee on Immunization Practices (ACIP) guidelines.  Recently the Committee recommended the live attenuated influenza vaccine (LAIV), also known as “nasal spray” flu vaccine, should not be utilized for the 2016-2017 flu season.  CPT 90672, the code utilized for the LAIV nasal vaccine, also known as “FluMist”, will be suspended effective September 1, 2016. 

8/31/2016 Billing Changes for Behavioral Health Assessments in Outpatient Agencies (HCPCS H0031)

Title: Billing Changes for Behavioral Health Assessments in Outpatient Agencies (HCPCS H0031)

Run Dates: 8/31/2016 through 9/30/2016

PV: PV 11

SoonerCare rules were revised during 2016 permanent rulemaking to remove specific minimum time requirements for behavioral health assessment services provided in outpatient behavioral health agencies. Previous rules required at least 1.5 hours in order to bill a low complexity assessment and over 2 hours to bill a moderate complexity assessment. Current reimbursement rates vary based on the complexity of the assessment as well as whether the assessment was performed for an adult or child member.

To correspond with the rule changes, new event-based reimbursement rates for assessments were created which are the same regardless of time spent on the assessment or the age of the client.   

Beginning September 1, 2016, the rate for assessments provided by fully licensed LBHPs will be $103.33. The rate for licensure candidates will be $90.41. The TF modifier (indicating low complexity) will no longer be reimbursable for H0031.

8/30/2016 Dear Provider Letter 2016-26

Title: Dear Provider Letter 2016-26

Run Dates: 8/31/2016-10/14/2016

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

 

Provider Letter 2016-26 serves to inform providers on the prior authorization process for definitive urine drug testing. Please post all comments by close of business, Friday, September 30, 2016 via the policy change blog. Thank you for your participation in this process.

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 recipient’s 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%.