Updated Notice of Hearing – Outpatient Facility Reimbursements

In response to the last hearing held in May, a task force meeting was held on July 24, 2018 to review proposed options for the J1 status indicator reimbursement methodology. The task force included representatives of facilities that provided input for or participated in the public hearing.

Providers are asked to request and review their impacted data as soon as possible in order to respond with a preference for the original proposed Limited J1 status indicator changes (Option1) or the second proposal for all CMS J1 status indicator bundling rules (Option 2) by Aug. 17, 2018, for consideration for the final update, due to be finalized by Sept. 1, 2018. This allows time for an additional task force meeting if necessary before the final direction is determined.

EGID held a public hearing May 5, 2018, regarding plans to implement outpatient reimbursement methodology to include J1 status indicator logic for HealthChoice and Department of Corrections claims. EGID continues to work with outpatient facilities across the state to ensure a successful implementation. Task force meetings will be conducted during the 3rd Quarter.

For further information and additional documents please visit http://omes.ok.gov/articles/update-notice-hearing-outpatient-facility-reimbursements.


DOC Network Providers

Welcome to the Department of Corrections (DOC) Provider Network. This site will allow you to search our provider network database, read related news and download network provider contracts. Questions and comments can be addressed here.



Fee Schedule Updates

Posted 02/10/2020

Future fee schedule updates for services provided by HealthChoice network providers are scheduled for:

ASC ADA ASA Bariatric CPT HCPCS MS-DRG MS-DRG LTCH OP Select inpatient Select outpatient/ASC
Jan1 A/C/D Comp Comp A/C/D A/C/D A/C/D Comp A/C/D Comp
April 1 Comp A/C/D A/C/D Comp Comp Comp A/C/D A/C/D
July 1 A/C/D A/C/D A/C/D A/C/D A/C/D Comp A/C/D A/C/D
Oct 1 A/C/D A/C/D Comp A/C/D A/C/D Comp Comp Comp Comp A/C/D

*Comp – Comprehensive *A/C/D – Adds, changes, deletes and other necessary updates

As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. When these modifications occur, EGID reviews them as quickly as possible and makes any necessary updates. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary.

The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban/rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area.

Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1, based on the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the ZIP code of its physical location which is included in the U.S. Census Bureau’s metropolitan core-based statistical area. On Jan. 1, the urban/rural indicator will be updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals.

For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area.

Inpatient and outpatient tier designations are defined as:

  • Tier 1 – Network urban facilities with greater than 300 beds.
  • Tier 2 – All other urban and non-network facilities.
  • Tier 3 – Critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
  • Tier 4 – All other network rural facilities.

Following each quarterly update of the HealthChoice fee schedule, outpatient rates for the procedures covered under the program will become fully phased in during the next quarterly update.

Fee schedule updates are reported in each quarterly issue of the Network News newsletter. If you need specific codes and allowable fees affected by these updates, please visit our website at https://gateway.sib.ok.gov/feeschedule/Login.aspx and view or download the latest fee schedule addendum. The fee schedule has not been publicly disclosed and is deemed confidential pursuant to 51 O.S. and should not be disseminated, distributed or copied to persons not authorized to receive the information. If you have questions or need additional information, please contact network management.

The following terms are used in the fee schedule:

  • BR: by report.
  • BR1: 60% of billed charges for Tiers 1 and 2; 70% of billed charges for Tiers 3 and 4.
  • BR2: 30% of billed charges for Tiers 1 and 2; 35% of billed charges for Tiers 3 and 4.
  • BR3: 0% of billed charges for Tiers 1, 2, 3 and 4.
  • Health: submit to health plan.
  • I: incidental.
  • IC: individual consideration.
  • NC: non-covered.
  • NOC: non-classified drugs.
  • Per Diem: per diem rate.
  • RX: submit to pharmacy administrator.
  • TM: use of time.
  • Physician assistant, nurse practitioner and clinical specialist are 85% of allowable fee.
  • Anesthesia conversion factors (2020).
    • $59 CRNA.
    • $62 M.D./D.O.
    • Anesthesia assistant is 50% of allowable fee.

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Department of Corrections - Network Providers

Posted 01/16/2020

The Department of Corrections plan is a managed health care program that provides comprehensive health and dental benefits to approximately 22,000 inmates sentenced to incarceration with the Oklahoma DOC.

The DOC plan is a partnership between the Oklahoma DOC, providers and the OMES Employees Group Insurance Division in the delivery of health care services and products that help control costs and assist in the provision of high-quality health care. Your help as a health care professional is needed to achieve this goal.

Entry into the DOC network is pre-approval for treatment.

The DOC will work with you to schedule a time that works for your office. A correctional officer will accompany all inmates at all times. If needed, the correctional officer will bring the inmate through an alternative entrance. The DOC will work with your staff to schedule appointments before or after regular patient hours, utilizing as much discretion as necessary to not interfere with other patient care.

Network DOC providers utilize the same allowable fees as HealthChoice network providers. The DOC fee schedule is available at https://gateway.sib.ok.gov/DOC/FeeSchedule/Login.aspx. Providers that are not part of the DOC network are paid per the Medicaid fee schedule.

Network providers are contractually obligated to provide health care services to inmates upon scheduling requests by the DOC.

For more information, call toll-free at 800-323-3710 or email EGID.DOCNetworkManagment@omes.ok.gov. A network management specialist will be happy to assist you.

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MS-DRG and MS-DRG LTCH Version 37 Fee Schedule Updates

Posted 11/07/2019

The HealthChoice and Department of Corrections annual MS-DRG updates to acute inpatient reimbursement include updates to tier designations based on the number of beds and provider type designation as urban or rural as contained within the current year’s final IPPS file.

For charges incurred on and after Oct. 1, 2019, the following changes are effective for the HealthChoice and DOC MS-DRG fee schedules:

MS-DRG
Tier 1 2 3 4
Outlier Threshold $124,291.00 $95,568.00 $80,954.00 $66,024.00
Marginal Cost Factor 0.32 0.35 0.41 0.50
Base Rate $11,204.00 $10,409.00 $11,755.00 $10,824.00

The market basket update factor is 3%.

The next comprehensive MS-DRG Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2020.

MS-DRG LTCH

For charges incurred on and after Oct. 1, 2019, the following changes are effective for the HealthChoice and DOC MS-DRG LTCH fee schedules:

  • Version 37 of the MS-DRG LTCH fee schedule has a base rate of $54,706.00. The outlier threshold is $26,778.00 while the cost-to-charge ratio is 0.233 and market basket update factor is 2.5%.

The next comprehensive MS-DRG LTCH Fee Schedule update will be effective for charges incurred on or after Oct. 1, 2020.

If you have any questions regarding these adjustments, please call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.

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Fee Schedule Updates for Jan. 1, 2019

Posted 11/26/2018

HealthChoice and the Department of Corrections have updated the following fee schedules for added, changed and/or deleted codes for charges incurred Oct. 1, 2018, and after: CPT/HCPCS, outpatient facility, ambulatory surgery center, and Select inpatient and outpatient. A comprehensive fee schedule update was done for MS-DRG, MS-DRG LTCH, inpatient and outpatient bariatric surgery for charges incurred Oct. 1, 2018, and after.

Inpatient and outpatient tier designations are updated annually on Oct. 1, based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers.

Please refer to the following fee schedule updates and timelines:

  • Jan. 1: Comprehensive fee schedule update for ADA, ASA, and Select inpatient and outpatient fee schedules.
  • Jan. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, and ASC.
  • April 1: Comprehensive fee schedule update for CPT/HCPCS, OP, and ASC.
  • April 1: Add, change and delete codes and other updates as necessary for Select inpatient and outpatient fee schedules.
  • July 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
  • Oct. 1: Add, change and delete codes and other updates as necessary for CPT/HCPCS, OP, ASC, and Select inpatient and outpatient fee schedules.
  • Oct. 1: Comprehensive fee schedule update for MS-DRG, MS-DRG LTCH, inpatient and outpatient bariatric surgery fee schedules (may be updated) and inpatient and outpatient tier designations.

As a reminder, the American Medical Association may periodically change, add or delete procedure codes throughout the year. When these modifications occur, HealthChoice and DOC will review the fee schedules as soon as possible and make any necessary changes. Additionally, HealthChoice and DOC make fee schedule updates on an ad hoc basis when needed.

If you have questions, contact network management at 405-717-8790 or toll-free 844-804-2642.

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Become a Department of Rehabilitation Services Provider

Posted 10/25/2017

Did you know that the Employees Group Insurance Division also maintains the Oklahoma Department of Rehabilitation Services Provider Network? DRS expands opportunities for employment, independent life and economic self-sufficiency by helping Oklahomans with disabilities bridge barriers to success in the workplace, school and home. DRS operates dozens of programs that help Oklahomans lead more independent and productive lives by aiding with:

  • Assistive technology.
  • Education.
  • Employment services.
  • Health and mental health services.
  • Housing assistance.
  • Personal assistance and in-home services.
  • Transportation.

The goal of DRS is to provide rehabilitation and the opportunity for independent living for disabled Oklahomans. Your help as a health professional is needed to achieve this goal. We encourage you to reach out and become a DRS network provider.

For more information, please visit our network provider home page at gateway.sib.ok.gov/DRS, email network management at EGID.DRSNetworkManagement@omes.ok.gov, or call us.

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Timely Filing for Medical and Dental Claims

Posted 10/25/2017

All HealthChoice and the Department of Corrections contracts contain timely filing provisions and HealthChoice encourages providers to file medical and dental claims within the constraints of their existing provider contracts.

As a courtesy, HealthChoice and the Department of Corrections have historically accepted medical and dental claims for dates of services received no later than the last day of the calendar year immediately following the calendar year in which the service or supply was rendered.

In order to move to a more industry standard time period for claims processing, effective Oct. 1, 2017, HealthChoice and the Department of Corrections will accept claims received no later than 365 days following the date the service or supply was rendered.

Providers are still strongly encouraged to file claims according to the timely filing limits contained within their existing HealthChoice and the Department of Corrections provider contracts. The extension is offered as a courtesy and is subject to change upon future notice.

If you have questions, contact network management. Refer to Network Provider Contact Information at the end of this newsletter.

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DOC Inmate Billing Information

Posted 04/20/12 - Updated 02/11/2019

The Oklahoma Department of Corrections (DOC) would like to remind all Network Providers that the terms of the DOC contract require that all fees are paid at 100% of the Allowed Charges with no inmate liability.

Providers are reminded to use the DOC inmate number as the member ID and to only bill paper claims on acceptable claim forms such as CMS 1500, UB-04 or ADA 2012.

To ensure that claims are processed promptly and correctly, Network Providers should submit claims electronically using Payer ID 71065 or use the direct data entry claim service available from Availity. The direct data entry of claims feature can be accessed through the provider portal at www.healthchoiceconnect.com.

Dental XChange is a free service for dental providers, for the direct data entry of claims. Dental providers can register for this free service at https://www.dentalxchange.com/home/Home.

Providers may also submit paper claims to:

Department of Corrections
PO Box 16532
Lubbock, TX 79490-6532

For charges incurred on or after November 1, 2011, non-Network Providers will be reimbursed at current Medicaid rates with no inmate liability.

For current fee schedule information, visit the DOC provider website at https://gateway.sib.ok.gov/DOC/ or call DOC Network Management at 405-717-8750 or toll-free 866-573-8462. Email inquiries can be sent to EGID.DOCNetworkManagement@omes.ok.gov.

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Other Information

Inmates will always be accompanied by a Department of Corrections employee.  If you have any questions concerning eligibility, please contact Debbie Elledge.

Case Management

If you have any questions concerning case management or discharge planning for inmate patients, please contact Jane Kirby.


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