Claims Processing Update – June 29, 2009
Clarification of HealthChoice Dental Benefits
Interest Payments to Providers
Payments for Orthodontic Services
Mammogram Claims Processing
Medicare Crossover Claims
Fax Your Certification Requests
ClaimLink is Now Available
OSEEGIB Administrator Apologizes for Delay
NPI Number Required on All Claims
EFT Form
Provider Relations Has New Director
Network Professional Provider Contract
Outpatient Fee Schedule
Inpatient Hospital Base Rates, Thresholds and Marginal Cost Factor
The Facility Dispute Resolution Process
ClaimCheck Frequently Asked Questions

Claims Processing Update – June 29, 2009:

EDS continues to make progress in programming its system to process claims for the various types of medical and dental services covered by HealthChoice. As of June 29, 2009, over 1.7 million claims have been processed totaling more than $270 million in payments. As indicated in previous communications with you, catching up on the backlog has been slow, but EDS is taking several steps to eliminate the backlog including adding a number of new positions, leveraging resources from other EDS accounts, and hiring an external vendor to provide additional onsite resources.

For assistance with a claim issue you have been unable to get resolved, please email EDSResolution@sib.ok.gov with the details of the claim. For security reasons, please include the member ID number in your email instead of the member’s Social Security number.

We deeply regret the difficulties the backlog of claims has caused and will continue to provide you with regular updates. Thank you for your patience.

For additional information on claims processing, click here.

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Clarification of HealthChoice Dental Benefits

We regret that there has been some confusion regarding certain HealthChoice dental benefits. We hope this will provide some clarification.

Dental Prophylaxis Coverage

HealthChoice covers dental prophylaxis treatments for children 0-12 years old (ADA code D1120) and for members 13 years of age and older (ADA code D1100). Two prophylaxis treatments are allowed per calendar year. All prophylaxis treatments must be billed on an 2006 ADA Dental Claim Form.

Coverage for Bitewing X-Rays

HealthChoice currently covers up to four bitewing x-rays per calendar year. The cost for bitewing x-ray services in excess of the maximum benefit , are the responsibility of the member.

The following codes are assigned by the American Dental Association for bitewing x-rays in its current Dental Terminology Code Book 2009-2010. All claims must be filed on an 2006 ADA Dental Claim Form:

D0274 – 4 bitewings
D0273 – 3 bitewings
D0272 – 2 bitewings
D0270 – 1 bitewing

The previous dental administrator applied this benefit, incorrectly, allowing eight bitewing x-rays per calendar year. Due to the initial confusion regarding the benefit for bitewing x-rays, HealthChoice continued to allow eight bitewings per calendar year for charges incurred before January 1, 2009.

HealthChoice has clarified this benefit discrepancy with the current dental administrator, EDS Administrative Services, and effective for charges incurred on or after January 1, 2009, the correct benefit of four bitewings per calendar year is being applied by EDS.

An article that sought to clarify the issue of coverage for bitewing x-rays appeared on the front page of the Spring Edition of the HealthChoice Provider newsletter, the Network News. The newsletter was mailed to all Network Providers in March of this year.

Fluoride Treatment Coverage

OSEEGIB covers fluoride treatments for children ages 0-15 (ADA code D1203). There is a limit of two fluoride treatment allowed per calendar year. Adult fluoride treatments (ADA code D1204) are not a covered benefit. All fluoride treatments must be billed on an 2006 ADA Dental Claim Form.

For Faster Processing of Dental Claims

For faster service for you, as a dental provider, please do not send things such as dental x-rays and molds with the claim or dental pre-determination unless they are requested by HealthChoice. This will also save you time and expense. EDS, the dental claims processing administrator, currently receives many dental items that are not necessary for claims payment.

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Interest Payments to Providers

Oklahoma State Statutes require interest to be paid to providers when clean claims are not processed within 45 days of receipt. In accordance with this requirement, the Oklahoma State and Education Employees Group Insurance Board, through its third party claims administrator, EDS Administrative Services, is paying interest for claims that meet the criteria required in the State Statues.

Prospective interest payments began on April 8, 2009. All claims paid on or after that date included interest payments if the claim was not processed and paid within the mandated 45 day period.

Recently, retrospective interest payments were initiated. Providers were sent communication through the mail with instructions on how to initiate the process of receiving interest for older claims. The process of distributing retrospective interest is being handled in three phases.

Questions and Answers regarding interest payments can be found using the Interest Payment Questions and Answers link following this article.

Any additional questions you may have concerning interest payments should be directed to EDS Administrative Services at 1-405-416-1780 or toll-free 1-800-782-5218.

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Payments for Orthodontic Services

Orthodontic Services are paid by the Plan at the established benefit level when the banding has been performed. The orthodontist is expected to file a claim for the services performed at the time the service is rendered. The Plan does not pay claims based on payment installments.

A small percentage of Orthodontists are filing claims with future billing dates. Claims with future billing dates will not be accepted and will be denied.

If you have any questions regarding the processing and payment of claims for orthodontic services, please contact EDS Administrative Services customer service at 1-405-416-1800 or toll free 1-800-782-5218.

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Mammogram Claims Processing

EDS Administrative Services, the claims administrator for HealthChoice, DOC and DRS has been experiencing a programming issue within its claims processing system. Due to this programming issue, mammogram claims have not been processed correctly. This issue has now been resolved and EDS is currently identifying all of the claims involved in the erroneous payments. Once these claims have been identified, EDS will make the appropriate adjustments and claim payments will be corrected. It is not necessary for providers to resubmit claims they believe are paid incorrectly.

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Medicare Crossover Claims

On February 2, 2009, EDS began accepting Medicare claims electronically from CMS. If you submitted a Medicare claim to CMS from December 15, 2008 thru February 1, 2009 for a HealthChoice member, you will need to resubmit the Medicare Electronic Remit Advice (ERA) or the Standard Paper Remit (SPR) to EDS, so that HealthChoice can consider the supplemental benefit. If you have already submitted the Medicare ERA or the SPR to EDS, please do not send it again.

If you have any questions, please call EDS at 1-405-416-1800 or 1-800-782-5218. TDD users call 1-405-416-1525 or toll-free 1-800-941-2160.

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Fax Your Certification Requests

APS Healthcare now offers fax submission of certification requests when using the Certification Request Form. The form allows providers to fax certification requests without having to speak with an intake coordinator. Fax your certification requests to 1-405-416-1755.

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ClaimLink is Now Available

You can now access ClaimLink to check the status of medical and dental claims, as well as deductible status. Click on ClaimLink in the menu to the left.

If you used ClaimLink prior to January 1, 2009, you must create a new account and login to access the site now.

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OSEEGIB Administrator Apologizes for Delay

Thank you for your patience and continued cooperation during this transition. Although initial progress was slow, we continue to work closely with EDS staff to ensure claims processing and customer services call centers are running according to all contractual guidelines.

OSEEGIB also continues to work with multiple provider associations to keep providers informed of progress and trends during this time.

The transition to EDS has brought to the forefront several differences related to coding and benefit determinations as previously applied by Fiserv Health Harrington. Additionally, EDS has had some challenges with its telephone call center. Updates on the correction and resolution of these issues are being addressed on the provider home pages and in upcoming issues of the provider newsletter, Network News.

Our focus remains on processing all claims received according to state guidelines and procedures as accurately and expeditiously as possible. Since the go-live date, EDS has processed 1.7 million provider claims, and more than $285 million in payments have been made through mid June. EDS is now operating close to the same capacity as the previous claims processor.

While OSEEGIB and EDS continue to work together to resolve coding and benefit determination issues, EDS has taken the following steps to resolve the call center issues:

• EDS has increased its original 46 phone lines to 120.
• EDS has increased its original telephone call center staff of 18 to 30. Call center hours are 7 a.m. to 7 p.m. Central time, Monday through Friday. Providers are encouraged to call between 7 a.m. to 9 a.m. and 4 p.m. to 7 p.m. when call volume is lower.

We are monitoring the progress and will ensure that EDS takes the steps necessary to provide the highest quality customer service to callers.

Again, we apologize for the inconveniences this implementation has created.

Sincerely,

Bill W. Crain
Administrator

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NPI Number Required on All Claims

Your individual NPI number is required on all paper and electronic claims submitted for processing. If you have not yet reported your NPI number to Provider Relations, please do so immediately to ensure quicker claims payment.

Please mail the NPI on your business letterhead to HealthChoice Provider Relations at the following address:

You can also fax it to 1-405-717-8977 or email it to oseegibproviderrelations@sib.ok.gov

If you have any questions, please contact HealthChoice Provider Relations at 1-405-717-8790 or toll-free 1-800-543-6044.

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EFT Form

Because the EFT process is the most efficient method of payment, it is OSEEGIB's goal that all HealthChoice providers adopt that capability in 2009. However, until all providers can complete their EFT applications and adapt their systems, we will continue to accommodate those who are in the change-over process and pay by check. Please click the link above for a copy of the EFT form.

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Provider Relations Has New Director

On May 18, 2009, Teresa South began her new duties as Director of Provider Relations. Ms. South comes to OSEEGIB with over 23 years of well-diversified experience in the medical field, especially in the areas of contracting and reimbursement analysis. She has experience working for a sleep lab, a physical therapy group, an OKC multispecialty group, a general medical surgical hospital, an orthopedic specialty hospital, and an outpatient imaging facility. Her hobbies include church activities, fishing and spoiling her grandchildren.

She plans to schedule future onsite visits with some of our Network Providers just as soon as she gets more settled in her new position. Meanwhile, she would welcome calls or emails from providers.
Her contact information is:
Teresa South, Director, Provider Relations – tsouth@sib.ok.gov
1-405-717-8627 or toll-free 1-800-543 6044 ext. 8627

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Network Professional Provider Contract

This is a draft of the Network Professional Provider Contract (NPPC). This contract is intended for suppliers and practitioners who participate in the HealthChoice Provider Network other than inpatient and dialysis facilities. We are asking that you review the NPPC draft and send us your comments and/or suggestions regarding the language of the contract. It is very important that we receive comments from our providers as we move forward into final stages of its development. Please send your comments in writing to:

or email our HealthChoice Contract Specialist

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