We strive to make information readily available to your office. We understand that your office is affected by any changes to the contracts that you hold through Mercy Managed Care. In efforts to keep you updated, this section is designed to update you on contract information including: new contracts, contract terminations, rate updates, TPA changes, and miscellaneous other news.

Please be aware that not all rate changes or contract updates below will necessarily pertain to everyone. We are also not able to publish specific rate information online as that data is confidential. Please see the additional resources below that are available to you to confirm specific contract participation.

  • Mercy Network LLC providers: If you are participating with Mercy via a contract with Mercy Network LLC (this would include providers in Southwest Missouri,  Northwest Arkansas, Oklahoma and select providers in St. Louis), please reference your online matrix for specific contract participation.
  • Mercy PHO providers: If you are contracted with Mercy via the Mercy PHO (this would include the majority of providers in the St. Louis region), please reference your PHO contract and enrollment packet for a listing of the contracts you hold through Mercy.
  • Mercy employed/integrated providers in the St. Louis region: Please continue to reference the Managed Care hub on Baggot Street, and the Sharepoint site as your reference for contract participation.
  • All other Mercy employed/integrated providers: Please continue to use the Managed Care hub on Baggot Street as your reference for contract participation.

Provider Changes
As a contracted provider, it is important to notify us immediately of changes to your practice such as: a new provider joining the practice, changes in billing information, provider leaving the practice, or adding a new clinic location.  Notification may help avoid claim denials.  Please submit changes by fax 417-820-3821 or email. Please include a W-9 Form if the change involves a new billing address or tax identification number.

Humana Medicare Preventive Services Tip Sheet

January 30, 2018

Please review the attachment for tips related to Humana’s Medicare Preventive services.  Also on the attachment is a link to Humana’s Code Editing Questions.

Humana Medicare Preventive Services Coding Tip Sheet

Cigna Policy Updates – April, 2018

January 22, 2018

Please review the attached letter from Cigna regarding the following policy updates effective for services on or after April 15, 2018.

  • Obstructive Sleep Apnea Treatment Services
  • Pharmacy and Infusion Services

Cigna Policy Updates – April, 2018

HealthChoice: TPA Updates

January 22, 2018

HealthChoice

This is the sixth edition of the HealthChoice TPA updates. Please check the HealthChoice implementation page on our provider website frequently for updates at https://www.ok.gov/sib/Providers/New_Medical_and_Dental_Claims_Administrator.html.

URGENT – 2018 Claims Sent to Wrong TPA

Check your practice management system to make sure a new insurance company or payer record has been set up for 2018 HealthChoice claims. The new payer record should also include the new claims address, contact details for certifications/appeals, etc. These updates will assure your claims are going to the correct HealthChoice TPA and will continue to pay promptly. We are seeing a large number of claims being mailed to the old TPA for 2018 dates of service. These claims will be returned to the provider beginning Feb. 1, 2018, which will delay provider payments.

If You are Still Choosing the Direct Data Entry of Medical Claims

Availity is not yet available for the direct data entry of medical claims. In the meantime, you can mail or fax claims.

Please mail medical claims for 2018 dates of service to:

HealthChoice
P.O. Box 99011
Lubbock, TX 79490-9011

Fax claims toll-free to 800-496-3138.

Submit claims electronically using the HealthChoice payer ID 71064.

Direct Data Entry of Dental Claims

Dental claims can be submitted via DentalXChange Direct Data Entry under HealthChoice Oklahoma. This is a free option for dental claims. Additional details will be available soon on the HealthChoice TPA implementation webpage at the web address below. The DentalXChange registration page is located at https://register.dentalxchange.com/reg/login;jsessionid=4a61e8e6bd22f5dfa6e64e9af36d?0. For registration help, contact DentalXChange toll-free at 800-576-6412, ext. 455.

Please take time to review the HealthChoice TPA implementation page at https://www.ok.gov/sib/Providers/New_Medical_and_Dental_Claims_Administrator.html. This webpage has the most current information about the 2018 TPA change.

Register Today on the New Provider Portal

HealthChoice Connect is now live and available for provider registration at www.healthchoiceconnect.com. This portal offers the ability to:

  • View a copy of your ERA.
  • Check eligibility and benefits.
  • Check claim status for dates of service rendered in 2018.

You can register a large group with the TIN and any affiliated NPI. Multiple registrations are not required, but are supported if preferred. Contact the new TPA toll-free at 800-323-4314 with questions about registration.

New Payer IDs for 2018 are Active

The HealthChoice new payer ID 71064 and the Department of Corrections and the Department of Rehabilitation Services new payer ID 71065 are now live with Change Healthcare and all other clearinghouses for 837 electronic claims submissions.

HealthChoice payer ID 71064 is now live with clearinghouses Passport, Transunion, and DentalXChange for 270/271 transactions.

The TPA is actively working to set up connections with Change Healthcare and Availity for 270/271 transactions, we will send notification once this is available.

Helpful Hints: To ensure timely processing, HealthChoice encourages providers to submit claims, appeals and retroactive certifications as soon as possible for 2017. Please verify claim status for 2017 dates of service by contacting the claims payer or using ClaimLink before resubmitting to avoid unnecessary denials of duplicates. If submitting a corrected claim, please mark as such and include the original claim number to ensure processing and avoid denial as duplicate.

Cigna Coverage Policy Updates – March 1, 2018

January 17, 2018

Please review the attached letter from Cigna regarding the following policy updates effective for services on or after March 1, 2018.

  • Continuous Passive Motion Devices
  • Vitamin D Testing

Cigna – Coverage Policy Updates 030118

HealthChoice: Retrospective Certifications and Appeals for 2017 Dates of Service

January 16, 2018

 

Retrospective Certifications and Appeals for 2017 Dates of Service

Certification is required within three working days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures, or within one day following emergency/urgent services. If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10 percent penalty is applied. The member is not responsible for this 10 percent penalty. If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied.

Beginning Jan. 1, 2018, there is a new process for all certification reviews related to services rendered or certification decisions made in 2017. To appeal decisions or request a retrospective certification for a date of service prior to 2018:

  • Fax retrospective certification requests to 405-717-8947, Attn: HealthChoice 2017 Retro Cert Request.
  • Fax appeal requests for denied services to 405-717-8947, Attn: HealthChoice Medical Director.

Requests must:

  • Clearly state the provider of service, type of service, and dates of service for the retrospective request and/or appeal.
  • Include requester’s contact name, phone and fax number.
  • Include all pertinent medical records to justify the medical necessity of the request.

Appeals must:

  • Include a detailed letter of medical necessity from the treating provider with supporting documentation.
  • Include claim number of any denied claims.

The review process will be completed or a request for additional information will be sent to the requestor via fax within 10 business days. If a retrospective certification is approved, claim(s) should be resubmitted to the appropriate TPA for reprocessing. If an appeal is approved, the claim will be routed internally to the appropriate TPA for reprocessing. If a retrospective certification or an appeal is denied, a letter will be sent advising you of this decision and what other options may be available.

 

 

HealthChoice: Payer ID Delays

January 16, 2018

HealthChoice

The HealthChoice new payer ID 71064 for 2018 dates of service is now live with Change Healthcare and all other clearinghouses for 837 electronic claims submissions.

If you have questions about the new payer ID and EDI transactions, please call the claims administrator toll-free at 800-323-4314.

 

Anthem Network E-Update 1/10/2018

January 16, 2018
Important Update from Anthem 
Reimbursement Policy Update — Evaluation and Management Services and Related Modifiers 25 and 57

In the November 2017 Special Edition of Network Update for Missouri, and in the December 2017 edition of Network Update for Indiana, Anthem Blue Cross and Blue Shield (Anthem) shared upcoming changes to the Evaluation and Management Services and Related Modifiers 25 and 57 Professional Reimbursement Policy. The notice indicated that  evaluation and management services that are eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery would be reduced by 50%, beginning February 1, 2018 in Missouri and March 1, 2018 in Indiana. Please note, the following information updates the previously published policy information.

Beginning with dates of service on or after March 1, 2018, Evaluation and Management Services (CPT codes 99201-99215) that are eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery will be reduced by 25%. Minor surgeries have a global period of 0 or 10 days, and the impacted CPT codes are 10000-69999, excluding CPT 36415, 36416, and 69210. As a reminder, please review the guidelines on reporting Modifier 25 in Anthem’s reimbursement policy.

For more information, please see Professional Reimbursement policies online by going to anthem.com>Menu>Providers. Select your state, then Answers@Anthem>Reimbursement Policies — Professional.