OBH Facets Provider Selection Guidelines

Original Effective Date	05/12/2015
Revision Date	02/16/2026

Overview

This document provides instructions on determining and selecting appropriate provider record.

Alert

1	Verify exceptions:

If…	Then…
Autism Services	Refer to OBH Facets Autism Claims
ER DMHC	Refer to ER DMHC
ER Services	Refer to OBH Facets ER Services
ECT Services	Refer to OBH Facets ECT Treatment
Ambulance	Refer to OBH Facets Ambulance Charges
NHPRI health plan	Refer to OBH Facets Provider Selection (NHP)
Idaho Medical health plan	Refer to OBH Facets Idaho Provider Selection
MGB Medicaid health plan	Refer to OBH Facets MGB Medicaid Provider Selection
Medica Medicaid: CCBHC	Refer to OBH Facets Medica CCBHC Review Job Aid
Medica Medicaid: ARMHS and CTSS	Refer to OBH Facets Medica ARMHS and CTSS Provider Selection Guidelines
Medica Medicaid: Family and Children FQHC/RHC	Refer to OBH Facets Medica Family and Children FQHC/RHC Job Aid
Medicaid Reclamation	Refer to OBH Facets Medicaid Reclamation
All Others	Proceed to next step

ATTENTION PROCESSOR!

If steps below lead to denial, continue to Step 8 to review WFWM, WMWM, and Error Messages.
Messages may lead to provider pick exceptions; if exceptions do not apply, return to this policy.

2	Open claim image in DOC360:

If…	Then…
HCFA physician claim form	Proceed to next step.
UB04 facility claim	Follow facility path in policy.

Model	Description	Payment target
2A, 2E, 2I	Individual suffixes; payment to group not individual	Group
3A	Contracts loaded only under group suffix	Group

4	1A, AN, or No Group Model

Choice	Scenario	Action
1st	INN individual record	Select INN individual. Skip to Step 8.
2nd	OON individual record	Select OON individual. Skip to Step 8.
3rd	Individual billed; not in Facets	Submit OON ePUF for provider load.
4th	Individual not billed; group in Facets	Select group; Override > Deny All Claim Lines > FOD. Skip to Step 8.

5	2A, 2I Group Model — follow selection table (INN/OON individual vs group).
6	3A — Skip to Step 6 per model table.
7	3B — Skip to Step 7 per model table.

If…	Then…
Individual is billed — INN	Select group; process per INN benefit; next step.
Individual is billed — OON	Select group; Override > Deny all Claim Lines > FOF; next step.
Individual is not billed	Select group; Override > Deny all Claim Lines > FOD/FOF; next step.

Multiple matches: prefer In-Network. INN 2-point match; OON 3-point match. Double-click OK.

Applications > Provider > Group — search by TIN per claim form.

Applications > Provider > Practitioner — search by TIN; match DOC360 EIN.

After correct Facility/Group/Individual selection:

INN benefit → indicator INN; not INN → OON.

Multiple matches: select In-Network. INN 3-point match; OON per policy.

Code Descriptions	EOB Codes List · Medicare Reason Codes · UM Service Group Code Glossary
Terminology	Optum Glossary of Terms, Abbreviations and Acronyms

Verify revision table from video closing pages if needed.

Platforms	Facets
Audience(s)	Auditor · Processor · Adjuster
State/DIV(s)	All
LOB(s)	Commercial
Product(s)	OBH
Documentation Contact	Knowledge Management Request Form