OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

Part 1      GENERAL PROVISIONS

317:25-7-1.Purpose
[Revised 01-01-09]
The purpose of this Subchapter is to describe the rules governing the statewide SoonerCare program. The rules provide assurances that SoonerCare members have adequate access to primary care, while reducing costs and preventing unnecessary and inappropriate utilization.
317:25-7-2.SoonerCare Choice: overview
[Revised 01-01-09]
(a) The Oklahoma Health Care Authority (OHCA) operates a Primary Care Case Management (PCCM) system for SoonerCare Choice eligible members.  PCCM is a managed care model in which each enrollee has a medical home with a primary care provider (PCP).  Enrollees may select their own primary care provider or clinic as their PCP if that provider is enrolled with OHCA as a PCP and as a SoonerCare provider.  For those who do not choose a PCP, they will be assigned to one.  Members may change PCPs at any time.
(b) The PCP is paid a monthly care coordination payment in accordance with the conditions in the PCP's SoonerCare Choice contract to provide or otherwise assure the delivery of medically-necessary preventive and primary care medical services, including securing referrals for specialty services and prior authorizations for an enrolled group of eligible members, with the exception of services described in subsection (c) of this Section for which authorization is not required.  The PCP assists the member in gaining access to the health care system and monitors the member's condition, health care needs and service delivery.
(c) Services which do not require a referral from the PCP include preventive or primary care services rendered by another SoonerCare contracted provider, outpatient behavioral health agency services, vision services for children, dental services, child abuse/sexual abuse examinations, prenatal and obstetrical services, family planning services, emergency physician and hospital services, disease management services, and services delivered to Native Americans at IHS, tribal, or urban Indian clinics.  Female members may access a SoonerCare women's health specialist without a referral for covered routine and preventive health care services.  This is in addition to the enrollee's PCP if that source is not a woman's health specialist.
(d) SoonerCare Choice covered services delivered by the PCP are reimbursed at the SoonerCare fee schedule rate under the procedure code established for each individual service.  To the extent services are provided or authorized by the Primary Care Provider, the OHCA does not make SoonerCare Choice payments for services delivered outside the scope of coverage of the SoonerCare Choice program, thus a referral by the PCP does not guarantee payment.
(e) The PCP may charge a co-payment for services provided to SoonerCare members in accordance with OAC 317:30-3-5(d).
(f) Members with chronic conditions may elect to enroll in a health management program to improve their health.
(g) PCPs may elect to participate in Health Access Networks to improve access to care.
317:25-7-2.1.Medical residents [REVOKED]
[Revoked 12-11-08]
317:25-7-3.Definitions
[Revised 01-01-09]

The following words and terms, when used in this Subchapter, have the following meaning, unless the context clearly indicates otherwise:

"Aged, Blind and Disabled" means the Medicaid covered populations under 42 U.S.C., Section 1396a (a)(10)(A)(i) and (F).

"Board" means the board designated by the Oklahoma legislature to establish policies and adopt and promulgate rules for the Oklahoma Health Care Authority.

"CEO" means the Chief Executive Officer of the Oklahoma Health Care Authority.

"Custody" means the custodial status, as reported by the Oklahoma Department of Human Services.

"Medicaid" means the medical assistance program authorized by 42 U.S.C., Section 1396a et seq. The program provides medical benefits for certain low-income persons. It is jointly administered by the federal and state governments.

"Medicare" means the program defined at 42 U.S.C. ' 1395 et seq.

"OHCA" means the Oklahoma Health Care Authority.

"OKDHS" means the Oklahoma Department of Human Services.

"PCCM" means Primary Care Case Management.

"PCP" means Primary Care Provider, including a Provider or Physician Group.

"Primary Care Case Management" means a managed care health service delivery system in which health services are delivered and coordinated by Primary Care Providers.

"Primary Care Provider" means a provider under contract with the Oklahoma Health Care Authority to provide primary care services and case management, including securing all medically-necessary referrals for specialty services and prior authorizations.

"Provider or Physician Group" means a partnership, limited partnership, limited liability company, corporation or professional corporation composed of doctors of medicine and/or doctors of osteopathy and/or advanced practice nurses, and/or physician assistants who provide health care of the nature provided by independent practitioners and are permitted by state and federal law and regulations to receive SoonerCare provider payments.

"SoonerCare" means the Medicaid program administered by the Oklahoma Health Care Authority.

"SoonerCare Choice" means a comprehensive medical benefit plan featuring a medical home including a Primary Care Provider for each member.

317:25-7-4.Credentialling and e-credentialling [REVOKED]
[Revoked 8-03-99]
317:25-7-5.Primary care providers
[Revised 09-01-16]

For provision of health care services, the OHCA contracts with qualified Primary Care Providers. All providers serving as PCPs must have a valid SoonerCare Fee-for-Service contract as well as an exercised SoonerCare Choice addendum. Additionally, all PCPs, excluding Provider or Physician Groups, must agree to accept a minimum capacity of patients, however this does not guarantee PCPs a minimum patient volume. Primary Care Providers are limited to:

(1) Physicians. Any physician licensed to practice medicine in the state in which he or she practices who is engaged in a general practice or in family medicine, general internal medicine or general pediatrics may serve as a PCP. The Chief Executive Officer (CEO) of the OHCA may designate physicians to serve as PCPs who are licensed to practice medicine in the state in which they practice who are specialized in areas other than those described above. In making this determination, the CEO may consider such factors as the percentage of primary care services delivered in the physician's practice, the availability of primary care providers in the geographic area of the state in which the physician's practice is located, the extent to which the physician has historically provided services to SoonerCare members, and the physician's medical education and training.

(A) For physicians serving as SoonerCare Choice PCPs, the State caps the number of members per physician at 2,500. However, the CEO in his/her discretion may increase this number in under served areas based on a determination that this higher cap is in conformance with usual and customary standards for the community. If a physician practices at multiple sites, the capacity at each site is determined based on the number of hours per week the physician holds office hours, not to exceed one FTE. Thus, the physician cannot exceed a maximum total capacity of 2500 members.

(B) In areas of the State where cross-state utilization patterns have developed because of limited provider capacity in the State, the CEO may authorize contracts with out-of-state providers for PCP services. Out-of-State PCPs are required to comply with all access standards imposed on Oklahoma physicians.

(2) Advanced Practice Nurses. Advanced Practice Nurses who have prescriptive authority may serve as PCPs for the Primary Care Case Management delivery system if licensed to practice in the state in which he or she practices. Advanced Practice Nurses who have prescriptive authority may serve as PCPs for a maximum number of 1,250 members. However, the CEO in his/her discretion may increase this number.

(3) Physician Assistants. Physician Assistants may serve as PCPs if licensed to practice in the state in which he or she practices.  Physician Assistants may serve as PCPs for a maximum number of 1,250 members. However, the CEO in his/her discretion may increase this number.

(4) Indian Health Service (IHS) Facilities and Federally Qualified Health Center (FQHC) provider groups.

(A) Indian Health Service facilities whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements at OAC 317:30-5-1088 may serve as PCPs.

(B) Federally Qualified Health Centers whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements in OAC 317:30-5-660.2 may serve as PCPs.

(5) Provider or physician group capacity and enrollment.

(A) Provider or physician groups must agree to accept a minimum enrollment capacity and may not exceed 2,500 members per physician participating in the provider group.

(B) If licensed physician assistants or advanced practice nurses are members of a group, the capacity may be increased by 1,250 members if the provider is available full-time.
(C) Provider or physician groups must designate a medical director to serve as the primary contact with OHCA.

317:25-7-6.Primary Care Provider responsibilities
[Revised 01-01-09]
(a) Under the provisions of the SoonerCare Choice Contract, the contractor is responsible for providing care coordination services for all enrolled members on his/her panel.
(b) PCPs must provide access to medical care twenty-four hours per day, seven days a week, either directly or through coverage arrangements made with other providers, clinics, and/or local hospitals.
317:25-7-7.Referrals for specialty services
[Revised 09-01-15]

(a) PCPs are required to assure the delivery of medically necessary preventive and primary care medical services, including securing referrals for specialty services.  Some services, as defined in OAC 317:25-7-2(c) and OAC 317:25-7-10(b), do not require a referral from the PCP.  A PCP referral does not guarantee payment, as all services authorized by the PCP must be in the scope of coverage of the SoonerCare Choice program to be considered compensable.

(b) Pursuant to OAC 317:30-3-1(f), SoonerCare Choice referrals must always be made on the basis of medical necessity.  Referrals from the PCP are required prior to receiving the referred service, except for retrospective referrals as deemed appropriate by the PCP.

(c) The PCP and specialty provider are responsible for maintaining appropriate documentation of each referral to support the claims for medically necessary services.

(d) As approved and deemed appropriate, the OHCA may provide administrative referrals for specialty services.  Administrative referrals are only provided by the OHCA under special and extenuating circumstances.  Administrative referrals should not be requested as a standard business practice.  The OHCA will not process retrospective administrative referrals, unless one of the following exceptions applies:

(1) the specialty services are referred from an IHS, tribal, or urban Indian clinic;

(2) the specialty services are referred as the result of an emergency room visit or emergency room follow-up visit;

(3) the specialty services are referred for pre-operative facility services prior to a dental procedure; or

(4) the retrospective administrative referral request for specialty services is requested from the OHCA within 30 calendar days of the specialty care date of service.  If the retrospective administrative referral is requested within the 30 calendar days, the request must include appropriate documentation for the OHCA to approve the request.  Appropriate documentation must include:

(A) proof that the specialist has attempted to collect a PCP referral from the member's assigned PCP; and

(B) medical documentation to substantiate that the specialty services are medically necessary pursuant to OAC 317:30-3-1(f).

(e) Nothing in this section is intended to absolve the PCP of their obligations in accordance with the conditions set forth in their PCP SoonerCare Choice contract and the rules delineated in OAC 317:30.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.