Provider Billing And Procedures Manual

Provider Billing andProcedures ManualOklahoma Health Care AuthorityOctober 2021

Table of ContentsProvider Billing and Procedures ManualTable of ContentsTable of Contents. iiChapter 1: General Information . 12Chapter 2: Contacts and Resources . 14Provider Policies .14Payments .14Provider Contracts .15Provider Contract Maintenance .15Provider Resources .16OHCA Call Tree .16Provider Inquiries .17Call Centers .18Claims .18Eligibility Verification System (EVS) .19Member Inquiries .20SoonerCare Provider Portal .20Provider Training and SoonerCare Education Specialists .211.1.1OHCA Public Site .231.1.2OHCA Webpages .24Chapter 3: SoonerCare Provider Portal . 26Introduction .26Important Website Notes.26Section A: Accessing the SoonerCare Provider Portal .26Getting to the SoonerCare Provider Portal .27Registering for a Provider Portal Account .27Types of Web Users .28Forgot Password .29Section B: Web Features .29Broadcast/Global Messages .29Main Page .29Eligibility Tab .33Treatment History (Dental) .34Treatment History (Medical) .35Library Reference: OKPBPMRevision Date: October 2021Version 6.333332ii

Table of ContentsProvider Billing and Procedures ManualClaims Tab .36Search Claims .36Claim Submission .37Pricing Page .38Prior Authorizations Page .39Referrals .42Trade Files Page (Batch Submission) .43Help Page .45Logout Link.45Chapter 4: Member Eligibility Verification. 47Introduction .47Member ID Card .47Section B: Options to Verify Member Eligibility .48EVS/AVR .49Provider Portal .50Electronic Data Interchange (EDI) .51Chapter 5: Claim Completion. 53Introduction .53Section A: Paper Claim Recommendations .53Ordering Paper Claim Forms .54Section B: 1500, Professional, 837P.55The 1500 Health Insurance Claim Form .551500 Claims Field Descriptions/Instructions .57Direct Data Entry (DDE) Claim Submission – Professional .63DDE Professional Claim Submission Instructions .69Section C: UB-04, Institutional, 837I .72The UB-04 Universal Billing Claim Form .72UB-04 Claim Field Descriptions/Instructions .74Direct Data Entry (DDE) Claim Submission – Institutional .79DDE Institutional Claim Submission Instructions .82Direct Data Entry (DDE) Claim Submission Inpatient/Outpatient Crossovers .86Part A – Crossover Details at the Header Level .86Part B – Crossover Details on each line of service .87Section D: ADA 2012, Dental, 837D .89Library Reference: OKPBPMRevision Date: October 2021Version 6.333332iii

Table of ContentsProvider Billing and Procedures ManualThe ADA 2012 Paper Claim Form .89ADA 2012 Claims Field Descriptions/Instructions .91Direct Data Entry (DDE) Claim Submission – Dental .94DDE Dental Claim Submission Instructions .96Section E: Drug/Compound Prescription Drug, Pharmacy, NCPDP .98Drug/Compound Drug Claim Forms .98Drug Claim Form .99Pharmacy Drug Claims Field Descriptions/Instructions .100Compound Prescription Drug Claim Form .102Compound Prescription Drug Claim Form Field Description/Instructions .103Direct Data Entry (DDE) Claim Submission – Pharmacy, including compounds .104DDE Pharmacy Claim Submission Instructions .106Section F: Electronic Claim Attachments .108Helpful Tips .108Attachment Form Cover Sheet (HCA-13) .109Section G: Medicare-Medicaid Crossover Invoice .110HCA-28: Medicare-Medicaid Crossover Invoice Form - Inpatient Claims Special BatchProcessing ONLY .110Medicare-to-Medicaid Crossover Invoice Form (HCA-28) .111HCA-28 Form Field Descriptions/Instructions – Inpatient Claims .112HCA-28B: Medicare-Medicaid Crossover Invoice Form Outpatient and HCFA 1500Claims .113Medicare to Medicaid Crossover Invoice Form (HCA 28B).114HCA-28B Form Field Descriptions/Instructions for Outpatient and HCFA 1500 Claims.115Section H: Special Batch Process Claims (HCA-17) .117HCA-17 Form Claim Appeal and Review Cover Sheet .117Claim Appeal and Review Cover Sheet Form (HCA-17) .118Chapter 6: Electronic Data Interchange . 121Introduction .121EDI Resources .122Section A: Professional Claims (837 Professional) .122837 Professional Transaction .122Section B: Institutional Claims (837 Institutional) .123837 Institutional Transaction .123Library Reference: OKPBPMRevision Date: October 2021Version 6.333332iv

Table of ContentsProvider Billing and Procedures ManualSection C: Dental Claims (837 Dental) .124837 Dental Transaction .124Section D: Pharmacy Claims .124Pharmacy Claims .124Section E: Claim Inquiries/Responses .125Claim Inquiry Transaction (Batch) .125Claim Inquiry Response Transaction (Batch) .126Section F: Eligibility Inquiries/Responses .126Eligibility Inquiry Transaction (Batch) .126Eligibility Inquiry Transaction .127Section G: Remittance Advice (RA) .127835 Remittance Advice .127Section H: Electronic Claims/PAs with Paper Attachments .128Section I: Electronic Media Types .129EDI Batched Electronic Transactions .129Section J: HIPAA Transaction and Code Set Requirements .129Chapter 7: Claims Resolution Process . 131Introduction .131Section A: Claim Creation.131Coding Orientation: R R Y Y J J J I I I I I I .131Section B: Data Entry .133MMIS Edits .133Section C: Resolutions .133Paid Claims .134Denied Claims .134Suspended Claims .134Resubmit Status .135Working Denied Claims .135Chapter 8: Paid Claim Adjustment Procedures . 138Introduction .138Section A: Adjustment Categories .138Non-Check Related Adjustments .138Check-Related Adjustments .139Negative Adjustment Amounts (Overpayments) .139Library Reference: OKPBPMRevision Date: October 2021Version 6.333332v

Table of ContentsProvider Billing and Procedures ManualPositive Adjustments (Underpayments) .140Section B: Adjustment Types and Workflow .141Non-Check Related Adjustments (regions 50 and 56) .141Check-Related Adjustments (regions 51 and 57) .141Chapter 9: Third Party Liability. 143Introduction .143OHCA Third Party Liability Program .144Section A: Services Exempt from Third Party .145Liability/Cost Avoidance Requirements .145Cost Avoidance .145Liability Insurance.146Section B: TPL Claim Processing Requirements .147Documentation Requirements .147Third Party Liability Identification .147Prior Authorization.148Billing Procedures .148Non-Covered Services or Lifetime Maximum Exceeded .148Subsequent Third-Party Liability Payment .149Remittance Advice Information .149Insurance Carrier Reimburses OHCA Member .149Section C: Coordination with Commercial Plans .150HMO Billing OHCA .150Section D: Medicare-OHCA Related Reimbursement .151Medicare Enrolled Participating Provider Reimbursement Process .151Medicare Enrolled Non-participating Provider Reimbursement Process .152Crossover Claims .152Prior Authorization.153Medicare Non-Covered or Denied Services .153Other TPL Resources .153Section E: Member TPL Update Procedures .153Automated Recovery, Resource Data Request Letters and Questionnaires .154General Update Procedures .154Telephone Inquiry Procedures .155Written Inquiry Procedures .155Library Reference: OKPBPMRevision Date: October 2021Version 6.333332vi

Table of ContentsProvider Billing and Procedures ManualSummary .155Chapter 10: Prior Authorization . 158Introduction .158Section A: Prior Authorization Requests .158Medical and DME Requests .158Dental Requests .158Pharmacy Requests .160Outpatient Rehabilitative Behavioral Health, Licensed Behavioral HealthProfessionals and Psychologist Services .160Inpatient Behavioral Health, Detoxification, Group Home and Therapeutic FosterCare Services .160Requests for Services to Illegal/Ineligible Aliens/Sooner To Be Sooners .161Section B: Prior Authorization Process .161Retroactive Authorization .162Section C: Reconsideration and Appeal Procedures .162Level 1—Reconsideration .162Level 2—Appeal .163Chapter 11: Financial Services . 166Introduction .166Section A: Payment Information .166Payments .166Section B: Remittance Advice (RA) .167Remittance Advice Section Descriptions .168Remittance Advice Sorting Sequence .170EOB Codes .170Remittance Advice Examples .171Section C: Electronic Remittance Advice .176Section D: 1099 & W-2s .176Section E: Stop Payments, Voids, Re-issuance .177Stop Payments .177Check Void .177Section F: Electronic Care Coordination Payments .178Chapter 12: SoonerCare Choice . 184Introduction .184Quality Assurance .184Library Reference: OKPBPMRevision Date: October 2021Version 6.333332vii

Table of ContentsProvider Billing and Procedures ManualCovered Members .185American Indian/Alaska Natives .185SoonerCare Choice Exempt .185Access to Care .186Emergency Care .186Member Enrollment/Disenrollment .187SoonerCare Choice Enrollment .187Choosing a PCP/CM .187Capacity (Number of Members requested per PCP/CM) .188Changing PCP/CMs .188Disenrollment at the Request of the PCP/CM .188Referrals.189Payment for Referred Services .190Documenting the Medical File .191Early and Periodic Screening Diagnosis and Treatment (EPSDT) .191Schedule of EPSDT Services.191Additional Requirements .191Reporting Requirements .192Reimbursement .192Care Coordination .192SoonerExcel Incentive .192Fee-For-Service .192Claims .193Care Management .193Population Care Management Services .193Chapter 13: Insure Oklahoma . 196Introduction .196Section A: What is the Insure Oklahoma Individual Plan? .196Persons Ineligible for the Insure Oklahoma Individual Plan .197Coverage for Children .197Medical ID Card .197Section B: Insure Oklahoma Individual Plan Billing Procedures .198PCP Payments .198Changes to Primary Care Physician Panels .198Library Reference: OKPBPMRevision Date: October 2021Version 6.333332viii

Table of ContentsProvider Billing and Procedures ManualEligibility .199Prior Authorization.199Adjustments .199Chapter 14: Pharmacy . 201Introduction .201Pharmacy Policy (Rules) .201Prescription Drug Benefit .202Product Based Prior Authorization (PBPA) .202Pharmacy Lock-In Program.203Durable Medical Equipment (DME) .204Chapter 15: LTC Nursing Facilities . 206Introduction .206Section A: LTC Nursing Facility Provider Eligibility .206Section B: PASRR .206Section C: ICF/IID Process .

Chapter 1: General Information Provider Billing and Procedures Manual Chapter 1: General Information The Oklahoma Health Care Authority (OHCA) is the state agency responsible for the administration of the Oklahoma Medicaid program. OHCA has a contractual agreement with Gainwell Technologies (Gainwell), previously DXC Technology (DXC) to be