2006 Global Messages

Effective Date

Subject

Message

12/21/2006

#171 Revisited: Billing Agents

Please ensure that your Billing Agents/Companies/ Clerks, etc., are advised of the following: Effective 01/01/2007 all claims submitted to the Health Care Authority must include a valid ICD-9 diagnosis code for claims processing.

Claims will deny if all necessary information is not included on the claim.

This requirement was previously addressed in Banner Message/Global Message #171: Valid Diagnosis Code Requirement.

Thank you for your continued service to SoonerCare members.

12/13/2006

More Provider Reps available

More Representatives Available to Assist You.

The Provider Service Unit has reorganized to better serve you. All Provider Service staff is available to assist you with any program question. This includes SoonerCare Traditional (FFS), SoonerCare Choice and other OHCA programs. They can also answer your questions concerning OHCA policy and rules and claims information. A complete listing of Provider Service Representatives is available on line at www.okhca.org or you may call them toll free at 1-877-823-4529, option 1.

SoonerCare Main Telephone Numbers
OKC Metro (405) 522-7366
State-wide Toll Free 1-877-823-4529

12/13/2006

Help Locating Specialty Providers

Need Help Locating a Specialty Provider?

Beginning January 1, 2007, Provider Service Representatives will maintain a listing of multiple specialty types that are currently accepting SoonerCare members (this specialty list was formerly managed by the Care Management department). Provider Services will now assist you in locating specialty providers for your patients. You may call them toll free at 1-877-823-4529, option 2.

07/26/2006 - 12/31/2006

Medicare Crossovers Update

Effective August 1, 2006, the Medicare claims crossover process will change. While you, the Medicaid Provider, will continue to file crossover claims as in the past, the crossovers will now come to OHCA from a central Medicare Coordination of Benefits Administrator, GHI, rather than from Trailblazers, BCBS of Arkansas, etc. During the transition, a slight lag time of 30-45 days in crossover payment may be experienced. We appreciate your patience in this matter. To avoid duplicate payments or adjustments, please do not file paper crossovers for 45 to 60 days from the time you receive a Medicare payment.

For more information on the new Medicare Coordinationi of Benefits Agreement, please visit the CMS/Centers for Medicare and Medicaid Services website at: www.cms.hhs.gov/COBAgreement/01_overview.asp

05/19/2006 - 12/31/2006

Hospital Claims - New Logic - Update

We recently sent out a message regarding outpatient hospital claims that will be reprocessed as described in Provider Letter 2006-05. We have monitored the payments processed by the new logic after 05/01/06. We are now reprocessing claims paid between 10/01/05 and 05/01/06, prior to the new logic being implemented. These claims will show as adjustments beginning on your May 31st remits.

Thank you for your continued services to Oklahoma's SoonerCare members.

04/30/2006 - 07/31/2006

Additional Procedure Codes – Family Planning Program

For Dates of Service on or after April 1, 2006, additional procedure codes have been approved for payment for members enrolled in SoonerPlan, family planning program. These additional codes are listed with the rest of the approved procedure codes on the Oklahoma Health Care Authority’s public website at www.okhca.org. Go to the “Provider” box, select “more options”, then under “types” select SoonerPlan-family planning. Scroll down until you see the list of procedure codes. Remember, these services are specifically for Family Planning. The appropriate primary diagnosis code must indicate the service is for family planning in order to receive reimbursement. If you have additional questions about SoonerPlan, please call 800-522-0114, or (405) 522-6205.

05/01/2006 - 10/30/2006

Drug Products / HCPCS Codes

Payment is not allowed to certain provider types for drug products using the HCPCS codes on CMS 1500, electronic 837, or the Professional claim form on the OHCA secure provider site. This is to ensure that proper licensing for handling prescription drug products is in place for the provider specialties that are allowed to continue to bill for drug products on these claims. Pharmacies must use the NDC and bill only through the point of sale system unless a claim is first billed to Medicare Part B. Crossover drug claims coming from Medicare will not be affected by this change.

Please note: One J code is an exception: J1642 Heparin Lock Flush. It can be billed by appropriate provider specialties including 050 Home Health Agency, 051 Specialized Home Nursing Services, 163 Skilled Nursing Agency, and 240 Pharmacy.

Thank you for your continued service to Oklahoma's SoonerCare members.

04/28/2006 - 06/30/2006

Hospital CLaims-New Logic

The outpatient hospital changes discussed in Provider Letter 2006-05 have been implemented. Claims will start paying using the new logic 5/1/06. We will monitor the new payments to assure claims are processing correctly and plan to begin the reprocessing of claims as described in Provider Letter 2006-05 on providers May 24th remits. We will confirm this date in a future message.

Thank you for your continued service to Oklahoma's SoonerCare members.

04/06/2006 - 05/13/2006

Psychologist Services Mass Adjustment

OHCA Rule 317:30-5-276, Coverage by category states there is "no coverage for adults for services by a psychologist." The MMIS system has been paying for these services in error. On April 5 a mass adjustment was completed to recoup all funds paid in error since 1-1-04. The recoupments made as a result of this adjustment will appear on your remittance advice in the Adjustments Section. If you have further questions about this transaction please call Debbie Spaeth at (405)522-7080.

04/08/2006

Unread PA's

Effective April 8, 2006 you will receive a new message when entering your secured web access. This new message will tell you how many unread PA (Prior Authorization) Notices you have received. Also, you will now have the ability to search for a member PA by member name, and if logged in under a group ID number, you will see all PAs for every provider within that group.

03/20/2006 - 12/12/2006

Email Notification

Dear Provider:

The Oklahoma Health Care Authority (OHCA) has updated our Web site and e-mail addresses to make it easier for everyone to find us.

We hope the new email address format is easier to remember. Just use the staff member's first name followed by a dot "." then the staff member's last name followed by @okhca.org. Example: suzie.employee@okhca.org.

Please update your OHCA contacts in your address book to the new format. Old email addresses for OHCA staff (employees@ohca.state.ok.us) will not work after June 30, 2006.

The OHCA Web site address has also changed! You can find us on the Internet via www.okhca.org. Please bookmark our new address. You can still locate us via the old Web site address, but the new one is shorter and easier to remember!

03/20/2006 - 12/12/2006

New Member ID Cards

**Beginning April 2006** - The Oklahoma Health Care Authority has redesigned the Medical Benefits Identification Card that is issued to members. OHCA will issue the new cards to first-time enrollees and to current members needing replacement cards. We will not replace every member's card. Current members who do not need replacement cards will continue to use their existing ID card. The new Medical Benefits Identification card is titled "SoonerCare Medical I.D. Card. The card has a white background, with green lettering, and our new logo. To view a picture of the card visit our website: www.okhca.org.

REMEMBER - These cards identify our members but do not guarantee eligibility or payment for services. Providers should verify coverage each time services are provided. To confirm eligibility call nationwide toll free 1-800-767-3949; Oklahoma City Metro (405) 840-0650 or access our secure Web site at www.okhca.org.

03/20/2006 - 12/12/2006

Medicare Adjustments

Medicare is conducting a mass adjustment due to re-pricing of the 2006 fee schedule. CMS is currently recycling all Medicare claims with service dates of 1-1-06 or after. All claims OHCA paid Medicaid as secondary to Medicare will need to be adjusted. Regretfully, OHCA can not adjust them systematically because the 837 transaction (electronic claim) will not contain the Oklahoma Medicaid ICN to make a match for an automatic adjustment to occur.

Each provider must submit adjustment request forms (HCA-14 or HCA-15) to the Adjustments Unit, for each affected, to be worked manually. Each request must have the original Medicare EOB and the Adjusted Medicare EOB attached for the claim to be properly adjusted by OHCA.

02/06/2006 - 06/01/2006

Mass Adjustment - Suspended Claims

The "In Process" section of this remittance advice may contain many suspended claims which have Individual Claim Numbers (ICN's) that begin with the digits 52. These claims are the result of a mass adjustment to fix errors in the way co payments were handled on claims. These claims are still being reviewed and investigated as to proper disposition of the claim. We will remove these claims from suspense status as soon as possible; however, it may be 6 weeks or longer before they are finalized. We apologize for the inconvenience. We are working to resolve this as quickly as possible.
Thanks you for the services you provide.

12/27/2002 - 12/31/2006

Remits

If you have any questions regarding this Remittance Advice, contact OHCA at (405) 522-6205 (Oklahoma City Metro Area) or outside the Metro Area at (800) 522-0114 between the hours of 7:30 am - 5:30 pm Monday through Friday. The mailing address for claim-related inquiries is:

Oklahoma Health Care Authority
C/O Customer Service
PO Box 18506
Oklahoma City, OK 73154-0506

Original, resubmitted, corrected or timely filed claims should continue to be mailed to the appropriate EDS address for faster processing. Do not send these claims to the above Customer Service address.

6/10/2005 - 6/30/2006

Written Inquiries - reminder

Reminder: To ensure that claims are properly handled, all paper correspondence sent to OHCA Customer Service must contain a cover letter or Medicaid Claim Inquiry Response Form OHCA-17 explaining what assistance is needed, along with a copy of the claim and all necessary documentation. Claims received without the necessary cover letter will be sent to process without further research by Customer Service.

Written inquiries with a copy of the claim are sent to:
OHCA Customer Service
P.O. Box 18506
Oklahoma City, Ok 73154

Thank you for your continued service to Oklahoma's Medicaid clients.

9/14/2005 - 6/1/2006

Related appropriate ICD-9 diagnosis procedure code(s)

This is a reminder that when billing for services a related appropriate ICD-9 diagnosis procedure code(s) must be put in the appropriate block on the CMS 1500 claim form and/or the UB-92 claim form. If a claim is submitted without a related appropriate ICD-9 diagnosis procedure code(s) the claim will be denied.

9/20/2005 - 6/1/2006

Obsolete J1563 & J1564

Please be advised that effective 10/01/2005 codes J1563 and J1564 are obsolete procedure codes and will no longer be accepted. Claims using these obsolete codes will be denied for dates of services 10-01-05 and after. The appropriate procedure codes, Q9941 through Q9944, should be billed for services rendered 10-01-05 and after.

9/28/2005 - 6/1/2006

Changes in Prescription Drugs

Effective October 1st, 2005 Atacand, Atacand HCT, Concerta, Focalin, Focalin XR, and Wellbutrin XL will move to Tier 1 and will no longer require a prior authorization as the manufacturers have entered into a supplemental rebate agreement. All ARBS now Tier 1.

Effective October 1st, 2005 SSNRIs (Selective Serotonin Norepinephrine Reuptake Inhibitors) will be added to step therapy. See chart below.

Effective October 1st, 2005 Advicor, Pravachol, Celexa and Lexxel will no longer be on Tier 1 and will now require a prior authorization or a previous trial on a Tier 1 medication.

Effective October 1st, 2005 Bladder Control medications will be added to step therapy. Ditropan XL is the only Tier 2 in this category.

Step therapy's goal is to optimize each client's medical therapy with medication that best treats the client's condition given their unique health status and circumstances. Tier 1 medications are preferred as the first step for treating a client's health condition. They are cost effective and are available without prior authorization from OHCA.

Providers who have clients with clinical exceptions may request a prior authorization to skip the step therapy process and receive the Tier 2 drug immediately. Prior authorization forms can be found on the OHCA website Prior Authorization.

Clients who have been on a Tier 2 drug within specified days of date of service will be ?grandfathered.? This allows a client to continue on a Tier 2 drug without a trial on a Tier 1 drug.

9/29/2005 - 6/30/2006

Modifier 25

Effective October 1, 2005, claims with modifier 25 will be denied unless sufficient documentation is attached to the claim. Claims utilizing modifier 25 must include sufficient documentation to justify payment for a significant and separately identifiable evaluation and management service by the same physician on the same day of another procedure or other service.

For assistance with conducting audits in your use of modifier 25 and/or to report errors of any type, please contact Pat Hornbook at (405)522-7155, or at Patricia.Holbrook@okhca.org. Please reference Dear Provider Letter OHCA 2005-30 for further explanation.

Thank you

10/24/2005 - 6/30/2006

Alien OB's

Effective October 1, 2005 DHS is no longer requiring the MA-13 form on Alien clients. All clients information must still be presented to the DHS office for certification of the case, but the exception dates will be forwarded by the providers to the Medical Authorization Unit at FAX# (405)530-3496. If you have further questions regarding this process please call (800)522-0114, option 9.

Thank you for your continuing support.

1/25/2006 - 12/31/2006

EPSDT Electronic / Internet Claim Changes

A new drop down box has been added to the professional Internet claim form. OHCA will use this information to track the treatment and referral of EPSDT services. The change affects both electronic and Internet claims.

The box has the 4 following values:

NU- = Not used. This should be used when there was no identified problem found during the screening and the provider is not treating or referring the child for treatment.

AV = Available but not used. This should be used when a referral for diagnostic or corrective treatment was refused for all health problems identified.

S2 = Under treatment. This should be used when the patient is already under diagnostic or corrective treatment for all health problems identified.

ST = New Services Requested. This should be used when referral for corrective treatment as a result of at least one health problem identified during an individual or periodic EPSDT screening service and were scheduled for another appointment with the screening provider or referred to another provider for further needed diagnostic or treatment services. (Do not include dental referrals).