SoonerCare A brief overview November 2009

SoonerCare A brief overview Agenda  Programs  Eligibility  Billing  Resources

SoonerCare A brief overview Programs  SoonerCare Traditional  SoonerCare Choice  SoonerCare Supplemental  Oklahoma Cares (BCC)  Perinatal Dental Program – PDEN

SoonerCare A brief overview Programs, cont.  SoonerPlan (Family Planning Waiver)  SoonerRide (NET)  Home and Community Based Waivers  Insure Oklahoma/OEPIC Individual Plan  Soon to Be Sooners

SoonerCare A brief overview Eligibility Process and Verification  Member files application with Department of Human Services (DHS) of Human Services (DHS)  Local DHS office processes application and enters approval or denial into OKDHS mainframe enters approval or denial into OKDHS mainframe  Real-time update to the Medicaid Management Information System (MMIS) Information System (MMIS)

SoonerCare A brief overview Eligibility Verification  There are four methods to verify eligibility:  SoonerCare Secure Site  Eligibility Verification System (EVS)  Electronic Date Interchange (EDI)  Swipe Machine

SoonerCare A brief overview Claim Submission  Claim Submission Types  SoonerCare Secure Site – Direct Data Entry (DDE)  Electronic Submission (EDI)

SoonerCare A brief overview Resources  OHCA Policy and Rules  CD Rom  Website –  Provider Billing and Procedure Manual  HIPAA Companion Documents

SoonerCare A brief overview Resources, cont.  On-site assistance  OHCA Provider Services  option 2  HP  6 Regional Field Consultants  Quick Reference Guide

Questions

SoonerCare Web Training and Billing Tips

Eligibility Suzie Sue

Utilizing the SoonerCare Secure Site

Claims

Outpatient

Adjustments

Resolving Denials

Did you know…  When using the ICN to research a claim, no other information is required. The ICN is specific to only one claim.  Using a member ID and the date of service will narrow the search results.

Medical Center Hospital A Resolving Denials

A new denial code (N84) will be used for DMHSAS services only. If a service is denied because the 1/12th cap has been met, the service will be denied with a N84 denial code.

Internal Control Number  ICN Internal Control Number identification Logical format Logical format – region code22 – region code 09 – year09 – year 019 – Julian date019 – Julian date – claim sequence – claim sequence

Internal Control Number, cont.  ICN Region code examples: 10 Paper Claim 10 Paper Claim 11 Paper Claim with an attachment 11 Paper Claim with an attachment 20 ASC X12N 837 electronic submission 20 ASC X12N 837 electronic submission 21 ASC X12N 837 electronic submission with attachment 21 ASC X12N 837 electronic submission with attachment 22 Web claim submission (DDE) 22 Web claim submission (DDE) 23 Web claim submission with attachment 23 Web claim submission with attachment series - Adjustment series - Adjustment Special process request Special process request

SoonerCare Questions