Utilization Review

Each HealthChoice Network Provider is contractually obligated to cooperate with all utilization review procedures established by OSEEGIB.

Certification

Certification is a medical review process that is performed to establish that a procedure, service or supply meets the Plan’s guidelines for medical necessity. Certification only establishes medical necessity and does not verify a member’s eligibility or guarantee the payment of Plan benefits.

• When certification is initiated and approved within the established time frame, and all other Plan rules and guidelines are met, your claim is paid according to Plan benefits and no penalty applies.
• When certification is not initiated and approved within the established time frame but is approved retrospectively, and all other Plan rules and guidelines are met, your claim is assessed a 10% penalty. The member is not responsible for paying this 10% penalty.
• When certification is initiated and denied, either prospectively or retrospectively, because medical necessity guidelines are not met, your claim is denied.
• When certification for diagnostic imaging is initiated and approved for a specific CPT code and the claim is submitted with a different CPT code, your claim is denied.

Once certification is approved, services and/or supplies can be provided. Please have the following member information available when requesting certification:

• Name and identification number
• Gender and age
• Member status (i.e., employee or dependent)
• Diagnosis
• Scheduled date of admission or service
• Planned procedures
• Provider name

Certification by APS Healthcare is required for the following procedures even when HealthChoice is the second or third payor:

• Inpatient admissions
• Transplants
• Selected outpatient procedures including:
  • Blepharoplasty
  • Breast implant removal
  • Breast reduction
  • Panniculectomy
  • Rhinoplasty
  • Scar revision
  • Surgical treatment of varicose veins
• All observation stays greater than 24 hours (with the exception of an observation stay less than 24 hours without room and board charges)
• Exhaustion of Medicare lifetime reserve days
• Diagnostic imaging procedures including:
  • Sinus CT and MRI
  • Spine CT and MRI
  • Orbit and Ear CT and MRI
  • Head/Brain CT and MRI
  • Upper Extremity MRI
  • Chest CT including Spiral CT (RAD)
  • PET Scans

Providers can contact APS Healthcare toll-free at 1-800-848-8121 and use the VoiCert automated phone system to request certifications. Call APS and follow the telephone prompts to leave certification requests through VoiCert.

Helpful Hint:
When HealthChoice is the second or third payor, (other group health insurance or Medicare primary) certification is required for the admissions and procedures listed above. This process helps protect both the provider and the member in the event the primary payor denies coverage or applies coverage exclusions or limitations. For example, the primary carrier denies a service that is covered by HealthChoice. If the provider did not request certification prior to the admission or procedure, HealthChoice may cover the service but a 10% penalty will apply to the provider even if the service meets certification requirements and is medically necessary as determined by OSEEGIB. This process will also be applicable when a member exhausts benefits under CMS and HealthChoice pays in the primary position and may pay any additional benefits.

Certification by the Health Care Management Division at OSEEGIB is required for the following services:

• Botox injections (non-cosmetic)
• Chiropractic therapy –visits exceeding 20 per calendar year must be certified; limited to 60 visits per calendar year.
• Dental accidents
• Durable medical equipment (DME)
• Enteral feeding
• Hearing aids – covered only for dependent children up to age 18
• Home health care – may be approved for up to 100 visits per calendar year
• Home infusion therapy
• Hospice – requires physician statement of life expectancy of six months or less
• Mental health home services – covered only for six biologically-based diagnoses
• Non-emergency ground or air ambulance
• Occupational therapy - visits exceeding 20 per calendar year must be certified; limited to 60 visits per year
• Oral Surgery – outpatient
• Orthotics and prosthetics
• Orthotripsy
• Outpatient hyperbaric oxygen therapy
• Outpatient mental health/substance abuse treatment – visits exceeding 15 per calendar year must be certified; limited to 26 visits per calendar year
• Physical therapy – visits exceeding 20 per calendar year must be certified; limited to 60 visits per calendar year
• Speech therapy – visits exceeding 20 per calendar year must be certified; limited to 60 visits per calendar year.
• Temporomandibular Joint Dysfunction (TMD) treatment
• Visco supplementation injections of the knee

Providers can contact HealthChoice Health Care Management at 1-405-717-8879 or toll-free 1-800-543-6044, ext. 8879.