SoonerCare A brief overview November 2009. SoonerCare A brief overview Agenda Programs Eligibility Billing Resources.

SoonerCareSoonerCareA brief overviewA brief overview

November 2009November 2009

SoonerCareSoonerCareA brief overviewA brief overview

AgendaAgenda ProgramsPrograms EligibilityEligibility BillingBilling ResourcesResources

SoonerCareSoonerCareA brief overviewA brief overview

ProgramsPrograms SoonerCare TraditionalSoonerCare Traditional SoonerCare ChoiceSoonerCare Choice SoonerCare SupplementalSoonerCare Supplemental Oklahoma Cares (BCC)Oklahoma Cares (BCC) Perinatal Dental Program – PDENPerinatal Dental Program – PDEN

SoonerCareSoonerCareA brief overviewA brief overview

Programs, cont.Programs, cont. SoonerPlan (Family Planning Waiver)SoonerPlan (Family Planning Waiver) SoonerRide (NET)SoonerRide (NET) Home and Community Based WaiversHome and Community Based Waivers Insure Oklahoma/OEPIC Individual PlanInsure Oklahoma/OEPIC Individual Plan Soon to Be SoonersSoon to Be Sooners

SoonerCareSoonerCareA brief overviewA brief overview

Eligibility Process and VerificationEligibility Process and Verification Member files application with DepartmentMember files application with Department

of Human Services (DHS)of Human Services (DHS) Local DHS office processes application and Local DHS office processes application and

enters approval or denial into OKDHS mainframeenters approval or denial into OKDHS mainframe Real-time update to the Medicaid Management Real-time update to the Medicaid Management

Information System (MMIS) Information System (MMIS)

SoonerCareSoonerCareA brief overviewA brief overview

Eligibility VerificationEligibility Verification There are four methods to verify eligibility:There are four methods to verify eligibility:

SoonerCare Secure SiteSoonerCare Secure SiteEligibility Verification System (EVS)Eligibility Verification System (EVS)Electronic Date Interchange (EDI)Electronic Date Interchange (EDI)Swipe MachineSwipe Machine

SoonerCareSoonerCareA brief overviewA brief overview

Claim SubmissionClaim Submission Claim Submission TypesClaim Submission Types

SoonerCare Secure Site – Direct Data SoonerCare Secure Site – Direct Data Entry (DDE)Entry (DDE)

Electronic Submission (EDI)Electronic Submission (EDI)

SoonerCareSoonerCareA brief overviewA brief overview

ResourcesResources OHCA Policy and RulesOHCA Policy and Rules

CD RomCD RomWebsite – Website – www.okhca.orgwww.okhca.org

Provider Billing and Procedure ManualProvider Billing and Procedure Manual HIPAA Companion DocumentsHIPAA Companion Documents

SoonerCareSoonerCareA brief overviewA brief overview

Resources, cont.Resources, cont. On-site assistanceOn-site assistance

OHCA Provider ServicesOHCA Provider Services 877-823-4529 option 2877-823-4529 option 2

HPHP 6 Regional Field Consultants6 Regional Field Consultants Quick Reference GuideQuick Reference Guide

QuestionsQuestions

SoonerCareSoonerCareWeb Training and Billing TipsWeb Training and Billing Tips

EligibilityEligibility

Suzie

012345678

012345678 Sue

Utilizing the SoonerCare Secure SiteUtilizing the SoonerCare Secure Site

012345678

200000000

200000000

ClaimsClaims

Outpatient

Adjustments

100123456

Resolving DenialsResolving Denials

Did you know…Did you know…

When using the ICN to research a claim, When using the ICN to research a claim, no other information is required. The ICN is no other information is required. The ICN is specific to only one claim.specific to only one claim.

Using a member ID and the date of service Using a member ID and the date of service will narrow the search results.will narrow the search results.

Medical Center Hospital

100123456A

Resolving Denials

012345678

2208000001234

2208000001234

012345678

2008999999999

2008000000000

1008999999999

2208000001234

A new denial code (N84) will be used A new denial code (N84) will be used for DMHSAS services only. If a for DMHSAS services only. If a

service is denied because the 1/12th service is denied because the 1/12th cap has been met, the service will be cap has been met, the service will be

denied with a N84 denial code.denied with a N84 denial code.

Internal Control NumberInternal Control Number

ICNICN

Internal Control Number identificationInternal Control Number identification Logical formatLogical format 22090193958652209019395865

•22 – region code22 – region code•09 – year09 – year•019 – Julian date 019 – Julian date •395865 – claim sequence395865 – claim sequence

Internal Control Number, Internal Control Number, cont.cont.

ICN Region code examples:ICN Region code examples: 10 Paper Claim10 Paper Claim 11 Paper Claim with an attachment11 Paper Claim with an attachment 20 ASC X12N 837 electronic submission20 ASC X12N 837 electronic submission 21 ASC X12N 837 electronic submission with 21 ASC X12N 837 electronic submission with

attachmentattachment 22 Web claim submission (DDE)22 Web claim submission (DDE) 23 Web claim submission with attachment23 Web claim submission with attachment 50-59 series - Adjustment50-59 series - Adjustment 90-95 Special process request90-95 Special process request

SoonerCareSoonerCareQuestionsQuestions