SoonerCare SoonerCare A brief overview A brief overview November 2009 November 2009
Dec 30, 2015
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