Transcription of Provider Billing and Procedures Manual
1 Provider Billing and Procedures Manual Oklahoma Health Care Authority October 2021. Table of Contents Provider Billing and Procedures Manual Table of Contents Table of ii Chapter 1: General Information .. 12. Chapter 2: Contacts and Resources .. 14. Provider Policies ..14. Payments ..14. Provider Contracts ..15. Provider Contract Maintenance ..15. Provider Resources ..16. OHCA Call Tree ..16. Provider Inquiries ..17. Call Centers ..18. Claims ..18. Eligibility Verification System (EVS) ..19. Member Inquiries ..20. SoonerCare Provider Portal ..20. Provider Training and SoonerCare Education Specialists ..21. OHCA Public Site ..23. OHCA Webpages.
2 24. Chapter 3: SoonerCare Provider Portal .. 26. Introduction ..26. Important Website Section A: Accessing the SoonerCare Provider Portal ..26. Getting to the SoonerCare Provider Portal ..27. Registering for a Provider Portal Account ..27. Types of Web Users ..28. Forgot Password ..29. Section B: Web Features ..29. Broadcast/Global Messages ..29. Main Page ..29. Eligibility Tab ..33. Treatment History (Dental) ..34. Treatment History (Medical) ..35. Library Reference: OKPBPM ii Revision Date: October 2021. Version 33332. Table of Contents Provider Billing and Procedures Manual Claims Tab ..36. Search Claims ..36. Claim Submission ..37. Pricing Page.
3 38. Prior Authorizations Page ..39. Referrals ..42. Trade Files Page (Batch Submission) ..43. Help Page ..45. Logout Chapter 4: Member Eligibility 47. Introduction ..47. Member ID Card ..47. Section B: Options to Verify Member Eligibility ..48. EVS/AVR ..49. Provider Portal ..50. Electronic Data Interchange (EDI) ..51. Chapter 5: Claim 53. Introduction ..53. Section A: Paper Claim Recommendations ..53. Ordering Paper Claim Forms ..54. Section B: 1500, Professional, The 1500 Health Insurance Claim Form ..55. 1500 Claims Field Descriptions/Instructions ..57. Direct Data Entry (DDE) Claim Submission Professional ..63. DDE Professional Claim Submission Instructions.
4 69. Section C: UB-04, Institutional, 837I ..72. The UB-04 Universal Billing Claim Form ..72. UB-04 Claim Field Descriptions/Instructions ..74. Direct Data Entry (DDE) Claim Submission Institutional ..79. DDE Institutional Claim Submission Instructions ..82. Direct Data Entry (DDE) Claim Submission Inpatient/Outpatient Crossovers ..86. Part A Crossover Details at the Header Level ..86. Part B Crossover Details on each line of service ..87. Section D: ADA 2012, Dental, 837D ..89. Library Reference: OKPBPM iii Revision Date: October 2021. Version 33332. Table of Contents Provider Billing and Procedures Manual The ADA 2012 Paper Claim Form ..89.
5 ADA 2012 Claims Field Descriptions/Instructions ..91. Direct Data Entry (DDE) Claim Submission Dental ..94. DDE Dental Claim Submission Instructions ..96. Section E: Drug/Compound Prescription Drug, Pharmacy, NCPDP ..98. Drug/Compound Drug Claim Forms ..98. Drug Claim Form ..99. Pharmacy Drug Claims Field Descriptions/Instructions ..100. Compound Prescription Drug Claim Form ..102. Compound Prescription Drug Claim Form Field Description/Instructions ..103. Direct Data Entry (DDE) Claim Submission Pharmacy, including compounds ..104. DDE Pharmacy Claim Submission Instructions ..106. Section F: Electronic Claim Attachments ..108. Helpful Tips.
6 108. Attachment Form Cover Sheet (HCA-13) ..109. Section G: Medicare-Medicaid Crossover Invoice ..110. HCA-28: Medicare-Medicaid Crossover Invoice Form - Inpatient Claims Special Batch Processing ONLY ..110. Medicare-to-Medicaid Crossover Invoice Form (HCA-28) ..111. HCA-28 Form Field Descriptions/Instructions Inpatient Claims ..112. HCA-28B: Medicare-Medicaid Crossover Invoice Form Outpatient and HCFA 1500. Claims ..113. Medicare to Medicaid Crossover Invoice Form (HCA 28B)..114. HCA-28B Form Field Descriptions/Instructions for Outpatient and HCFA 1500 Claims ..115. Section H: Special Batch Process Claims (HCA-17) ..117. HCA-17 Form Claim Appeal and Review Cover Sheet.
7 117. Claim Appeal and Review Cover Sheet Form (HCA-17) ..118. Chapter 6: Electronic Data Interchange .. 121. Introduction ..121. EDI Resources ..122. Section A: Professional Claims (837 Professional) ..122. 837 Professional Transaction ..122. Section B: Institutional Claims (837 Institutional) ..123. 837 Institutional Transaction ..123. Library Reference: OKPBPM iv Revision Date: October 2021. Version 33332. Table of Contents Provider Billing and Procedures Manual Section C: Dental Claims (837 Dental) ..124. 837 Dental Transaction ..124. Section D: Pharmacy Claims ..124. Pharmacy Claims ..124. Section E: Claim Inquiries/Responses ..125. Claim Inquiry Transaction (Batch).
8 125. Claim Inquiry Response Transaction (Batch) ..126. Section F: Eligibility Inquiries/Responses ..126. Eligibility Inquiry Transaction (Batch) ..126. Eligibility Inquiry Transaction ..127. Section G: Remittance Advice (RA) ..127. 835 Remittance Advice ..127. Section H: Electronic Claims/PAs with Paper Attachments ..128. Section I: Electronic Media Types ..129. EDI Batched Electronic Transactions ..129. Section J: HIPAA Transaction and Code Set Requirements ..129. Chapter 7: Claims Resolution Process .. 131. Introduction ..131. Section A: Claim Coding Orientation: R R Y Y J J J I I I I I I ..131. Section B: Data Entry ..133. MMIS Edits ..133.
9 Section C: Resolutions ..133. Paid Claims ..134. Denied Claims ..134. Suspended Claims ..134. Resubmit Status ..135. Working Denied Claims ..135. Chapter 8: Paid Claim Adjustment Procedures .. 138. Introduction ..138. Section A: Adjustment Categories ..138. Non-Check Related Adjustments ..138. Check-Related Adjustments ..139. Negative Adjustment Amounts (Overpayments) ..139. Library Reference: OKPBPM v Revision Date: October 2021. Version 33332. Table of Contents Provider Billing and Procedures Manual Positive Adjustments (Underpayments) ..140. Section B: Adjustment Types and Workflow ..141. Non-Check Related Adjustments (regions 50 and 56).
10 141. Check-Related Adjustments (regions 51 and 57) ..141. Chapter 9: Third Party 143. Introduction ..143. OHCA Third Party Liability Program ..144. Section A: Services Exempt from Third Party ..145. Liability/Cost Avoidance Requirements ..145. Cost Avoidance ..145. Liability Section B: TPL Claim Processing Requirements ..147. Documentation Requirements ..147. Third Party Liability Identification ..147. Prior Billing Procedures ..148. Non-Covered Services or Lifetime Maximum Exceeded ..148. Subsequent Third-Party Liability Payment ..149. Remittance Advice Information ..149. Insurance Carrier Reimburses OHCA Member ..149. Section C: Coordination with Commercial Plans.
