Facility Select Amendment (Select Amendment to the HealthChoice Network Facility Contract)
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Amendment establishing EGID payment rules for identified inpatient/outpatient bundled services, implant reimbursement rules, billing and audit requirements, and Select Fee Schedule provisions for contracted Facilities in the HealthChoice network.
EGID agrees to pay the Facility for inpatient and outpatient bundled services identified in Attachment A and to pay Allowable Fees as indicated in the Select Fee Schedule.
Implements separate reimbursement rules for implants, including invoice-cost billing, documentation, and quarterly audits with potential repayment/refund requirements.
Section VI (18) amended to require Facilities to bill within 180 days, use current revenue/CPT/HCPCS/diagnosis codes, and furnish records upon request.
Bilateral procedures will be reimbursed at 150% of the Select Allowable Fee.
Select Amendment Coverage and Billing Criteria
Select Amendment coverage and billing criteria
Coverage and reimbursement criteria under this Select Amendment:
Separate implant reimbursement
- EGID reimburses separately for implants listed on the implant list on the HealthChoice provider website.
- EGID does not reimburse separately for mesh, sutures, suture anchors, staples, wire, catheters, vascular stents, intestinal tract stents, devices associated with sterilization or fertility procedures, or implants from an inpatient service.
- A Facility may request review of an implant for inclusion by providing supporting documentation to EGID.NetworkManagement@omes.ok.gov.
Implant billing and reimbursement conditions
- Implants must be billed at invoice cost, less any rebates and/or discounts received by the Facility; EGID will allow up to the net cost, including prorated shipping, handling, and tax.
- If no CPT/HCPCS code exists for an implant, EGID will accept an appropriate unlisted CPT/HCPCS code with an explanation of each item and corresponding charge.
- Facilities must include a description of implant items on both electronic and paper claims.
- Upon request, EGID requires the actual invoice for the implant billed; invoices must identify which implants listed on the invoice apply to the claim being audited.
Audit and enforcement for implants
- EGID may conduct quarterly retrospective audits of Facility implant charges.
- Upon audit, EGID will request invoices and any other documentation showing discounts not listed on the invoice; the Facility has 30 days to submit the requested information.
- If EGID finds the Facility billed more than acquisition cost, the Facility must refund any overpayments and provide copies of invoices for subsequent claims prior to payment.
- If the Facility continues to bill above acquisition cost or fails to provide requested invoices within the required timeframe, EGID will no longer allow separate reimbursement for implants.
Coding conflicts and coverage
- If a Facility bills a CPT/HCPCS code that EGID considers to be part of a more comprehensive code billed the same date of service, only the more comprehensive code is covered for reimbursement.
- EGID shall consider multiple combinations of CPT/HCPCS codes as specified within the Select Fee Schedule.
Timeliness and billing requirements
- The Facility shall bill EGID on standard forms acceptable to EGID within 180 days of providing the services, or within 180 days of receipt of a primary payor's explanation of benefits, or from discovery that EGID is responsible for payment.
- The Facility shall use current revenue codes, ADA, CPT codes with appropriate modifiers, HCPCS codes, and ICD or DSM diagnosis codes, when applicable.
- The Facility shall furnish, upon request at no cost, all appropriate medical and billing records reasonably required by EGID to verify and substantiate services and charges.
Required Coding, Invoice Practices, and Implant Reimbursement
| CPT/HCPCS | Use most descriptive CPT/HCPCS codes for implants; unlisted codes accepted with explanation if no specific code exists. |
| Revenue/CPT/HCPCS/ICD/DSM | Facilities must use current revenue codes, ADA, CPT with modifiers, HCPCS, and ICD or DSM diagnosis codes when applicable. |
Billing, Documentation, Audits, and Implant Inclusion Requests
Billing, documentation, audit response, and implant inclusion requests
Facilities must bill using current revenue codes, ADA, CPT (with appropriate modifiers), HCPCS, and ICD or DSM diagnosis codes and submit claims within 180 days of providing services, receipt of the primary payor’s EOB, or discovery that EGID is responsible. Upon request, Facilities must furnish all appropriate medical and billing records at no cost to EGID to verify services and charges; invoices and documentation for implants must be provided within 30 days when requested during an audit. Facilities may request review for implant inclusion by submitting supporting documentation to EGID.NetworkManagement@omes.ok.gov.
- Bill on standard forms acceptable to EGID (alternate forms only if approved).
- Timely submission window: bill within 180 days.
- If EGID requests implant invoices during an audit, the Facility has 30 days to submit invoices and any documentation of discounts not listed on the invoice.
- Include implant descriptions on both electronic and paper claims.
Key Definitions
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