Transcript SoonerCare A brief overview

SoonerCare
A brief overview
November 2009
SoonerCare
A brief overview
Agenda
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Programs
 Eligibility
 Billing
 Resources
SoonerCare
A brief overview
Programs
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SoonerCare Traditional
SoonerCare Choice
SoonerCare Supplemental
Oklahoma Cares (BCC)
Perinatal Dental Program – PDEN
SoonerCare
A brief overview
Programs, cont.
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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)
 Local DHS office processes application and
enters approval or denial into OKDHS mainframe
 Real-time update to the Medicaid Management
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 – www.okhca.org
Provider Billing and Procedure Manual
HIPAA Companion Documents
SoonerCare
A brief overview
Resources, cont.
On-site assistance
OHCA Provider Services
877-823-4529 option 2
HP
6 Regional Field Consultants
Quick Reference Guide
Questions
SoonerCare
Web Training and Billing Tips
Eligibility
012345678
012345678
Sue
Suzie
Utilizing the SoonerCare Secure Site
012345678
Claims
200000000
200000000
Outpatient
Adjustments
100123456
Resolving Denials
Did you know…
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When using the ICN to research a claim, no
other information is required. The ICN is
specific to only one claim.
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Using a member ID and the date of service will
narrow the search results.
Resolving Denials
Medical Center Hospital
100123456A
2208000001234
2208000001234 012345678
012345678
2008999999999
2008000000000
1008999999999
2208000001234
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
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ICN
Internal Control Number identification
 Logical format
 2209019395865
•22 – region code
•09 – year
•019 – Julian date
•395865 – claim sequence
Internal Control Number, cont.
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ICN Region code examples:
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10 Paper Claim
11 Paper Claim with an attachment
20 ASC X12N 837 electronic submission
21 ASC X12N 837 electronic submission with
attachment
22 Web claim submission (DDE)
23 Web claim submission with attachment
50-59 series - Adjustment
90-95 Special process request
SoonerCare
Questions