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Part       GENERAL MEDICAL PROGRAM INFORMATION

317:30⊂chapter=3∂=3--39.Home and Community Based Services Waivers
[Revised 10-01-15]

The Oklahoma Health Care Authority operates or oversees the operation of several Home and Community Based Services waivers.  The waivers allow individuals with physical or intellectual disabilities, requiring institutional level of care, the opportunity to reside at home or in a community based setting, while receiving institutional level of care services. Brief summaries of the Waivers are set forth in OAC 317:30-3-40 and OAC 317:30-3-41.  Detailed information about each Waiver is available per the following citations:

(1) Home and Community Based Services Waivers for People with Intellectual Disabilities and Related Conditions can be found at OAC 317:40-1-1 et seq.

(2) Home and Community Based Services Waivers for People with Physical Disabilities:

(A) ADvantage Waiver information is available per OAC 317:30-5-760 et seq.

(B) Medically Fragile Waiver information is available per OAC 317:50-1-1 et seq.

 

317:30⊂chapter=3∂=3--40.Home and Community-Based Services Waivers for persons with intellectual disabilities or certain persons with related conditions
[Revised 06-25-12]
(a) Introduction to HCBS Waivers for persons with intellectual disabilities. The Medicaid Home and Community-Based Services (HCBS) Waiver programs are authorized in accordance with Section 1915(c) of the Social Security Act.
(1) Oklahoma Department of Human Services Developmental Disabilities Services Division (DDSD) operates HCBS Waiver programs for persons with intellectual disabilities and certain persons with related conditions. Oklahoma Health Care Authority (OHCA), as the State's single Medicaid agency, retains and exercises administrative authority over all HCBS Waiver programs.
(2) Each waiver allows for the provision of specific SoonerCare-compensable services that assist members to reside in the community and avoid institutionalization.
(3) Waiver services:
(A) complement and supplement services available to members through the Medicaid State Plan or other federal, state, or local public programs, as well as informal supports provided by families and communities;
(B) can only be provided to persons who are Medicaid eligible, outside of a nursing facility, hospital, or institution; and
(C) are not intended to replace other services and supports available to members.
(4) Any waiver service must be:'
(A) appropriate to the member's needs; and
(B) included in the member's Individual Plan (IP).
(i) The IP:
(I) is developed annually by the member's Personal Support Team, per OAC 340:100-5-52; and
(II) contains detailed descriptions of services provided, documentation of amount and frequency of services, and types of providers to provide services.
(ii) Services are authorized in accordance with OAC 340:100-3-33 and 340:100-3-33.1.
(5) DDSD furnishes case management, targeted case management, and services to members as a Medicaid State Plan service under Section 1915(g)(1) of the Social Security Act in accordance with OAC 317:30-5-1010 through 317:30-5-1012.
(b) Eligible providers. All providers must have entered into contractual agreements with OHCA to provide HCBS for persons with an intellectual disability or related conditions.
(1) All providers, except pharmacy, specialized medical supplies and durable medical equipment providers must be reviewed by OKDHS DDSD. The review process verifies:
(A) the provider meets the licensure, certification or other standards as specified in the approved HCBS Waiver documents; and
(B) organizations that do not require licensure wishing to provide HCBS services meet program standards, are financially stable and use sound business management practices.
(2) Providers who do not meet the standards in the review process will not be approved for a provider agreement.
(3) Provider agreements with providers that fail to meet programmatic or financial requirements may not be renewed.
(c) Coverage. All services must be included in the member's IP. Arrangements for services must be made with the member's case manager.
317:30⊂chapter=3∂=3--41.Home and Community Based Services Waivers for persons with physical disabilities
[Revised 10-01-15]

(a) ADvantage Waiver.  The ADvantage Waiver Program is a Medicaid Home and Community Based Services (HCBS) Waiver used to finance non-institutional long-term care services through Oklahoma's SoonerCare program for elderly and disabled individuals in specific waiver areas.  To receive ADvantage Program services, individuals must meet the nursing facility level of care criteria, be age 65 years or older, or age 21 or older if disabled. ADvantage Program members must be SoonerCare eligible and reside in the designated service area.  The number of members in the ADvantage Waiver is limited.

(b) Medically Fragile Waiver.  The Medically Fragile Waiver Program is a Medicaid Home and Community Based Services (HCBS) Waiver used to finance non-institutional long-term care services through Oklahoma's SoonerCare program for medically fragile individuals. To receive Medically Fragile Program services, individuals must be at least 19 years of age, be SoonerCare eligible, and meet the OHCA skilled nursing facility (SNF) or hospital level of care (LOC) criteria.  Eligibility does not guarantee placement in the program as Waiver membership is limited.

317:30⊂chapter=3∂=3--42.Services in a Nursing Facility (NF)
[Revised 6-25-12]
Nursing facility services are those services furnished pursuant to a physician's orders which require the skills of technical or professional personnel, e.g., registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists or audiologists. This care is provided by nursing facilities licensed under State law to provide, on a regular basis, health related care and services to individuals who do not require hospitalization but whose physical or mental condition requires care and services above the level of room and board which can be made available to them only through a nursing facility.
(1) To be eligible for nursing facility services the individual must:
(A) Require a treatment plan involving the planning and administration of services which require skills of licensed technical or professional personnel that are provided directly or under the supervision of such personnel and are prescribed by the physician;
(B) Have a physical impairment or combination of physical and mental impairments;
(C) Require professional nursing supervision (medication, hygiene and dietary assistance);
(D) Lack the ability to care for self or communicate needs to others; and
(E) Require medical care and treatment in a nursing facility to minimize physical health regression and deterioration. A physician's order and results from a standardized assessment which evaluates type and degree of disability and need for treatment must support the individual's need for NF level of care. Only standardized assessments approved by the OHCA and administered in accordance with Medicaid approved procedures shall be used to make the NF level of care determination.
(2) If the individual experiences mental illness or an intellectual disability or a related condition, payment cannot be made for services in a nursing facility unless the individual has been assessed through the Preadmission Screening and Resident Review (PASRR) process and the appropriate MR or MI authority has determined that nursing facility services are required. If it is determined that the patient also requires specialized services, the state must provide or arrange for the provision of such services. These determinations must be made prior to the patient's admission to the nursing facility.
(3) Payment cannot be made for an individual who is actively psychotic or capable of imminent harm to self or others (i.e., suicidal or homicidal).
(4) Payment is made to licensed nursing facilities that have agreements with the Authority.
317:30⊂chapter=3∂=3--43.Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities(ICF/IID)
[Revised 09-01-17]

Services in an ICF/IID facility are provided to individuals per OAC 317:30-5-122 and OAC 317:35-9-45.

 

 

317:30⊂chapter=3∂=3--44.Personal care
[Revised 09-01-17]

Personal care is a service provided in a member's home. To receive the service, the member must have met the appropriate level of care in accordance with procedures found in OAC 317:35-9. In geographic areas designated as ADvantage Program phase in areas, personal care services may be provided by agency providers who contract with the Medicaid agency for the provision of services. The service may be provided by individual personal care providers in geographic areas where there is insufficient agency providers to adequately serve the population.



317:30⊂chapter=3∂=3--45.Services for persons age 65 or older in mental health hospitals
[Issued 1-05-95]
Services for persons age 65 years or older in mental health hospitals are mental health services provided in an inpatient hospital setting to eligible categorically needy individuals whose condition cannot adequately be treated on an outpatient basis.

317:30⊂chapter=3∂=3--46.Services for persons infected with tuberculosis
[Revised 09-12-14]

(a) Oklahoma Medicaid provides optional coverage of tuberculosis (TB) related services for certain TB infected individuals. Services covered under this program are not restricted to the Medicaid scope of coverage or limitations.  Services for TB infected individuals that exceed the scope of Medicaid services must be prior authorized. Individuals eligible only under the optional TB-related services program can receive TB related services such as:

(1) Prescribed medications:

(A) Prescription drugs indicated for the treatment of TB up to the Medicaid established prescription limit; and

(B) Other drugs related to the treatment of TB beyond the prescriptions covered under Medicaid, require prior authorization obtained from the University of Oklahoma College of Pharmacy using form "Petition for TB Related Therapy".

(2) Physician services:

(A) Physician services include:

(i) ambulatory physician services;

(ii) office visits; and

(iii) ambulatory surgery and such, but not including inpatient services.

(B) Office visits are not limited for TB infected persons.  However, prior authorization is required when the limit under Medicaid is exceeded;

(3) Outpatient hospital services;

(4) Rural Health Clinic services;

(5) Federally Qualified Health Clinic services;

(6) Laboratory and x-ray services. Necessary laboratory and x-ray services (including services to confirm presence of TB infection) are covered for infected persons. Screening tests to detect and confirm presence of TB do not require prior authorization;

(7) Tuberculosis Clinic services (See 317:30-5-1159 for description of these services); and

(8) Targeted Case Management services.

(b) Persons eligible for services only under optional TB coverage do not receive the full range of Medicaid benefits. Coverage is limited as set out in this Section.

(c) Persons eligible under Medicaid who are infected with TB may also be eligible for TB services and receive these extended benefits.
317:30⊂chapter=3∂=3--46.1.Poison control services [REVOKED]
[Revoked 7-01-98]

317:30⊂chapter=3∂=3--47.Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--48.Periodicity schedule [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--49.Initial screening examination [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--50.Screening components [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--51.Diagnosis and treatment [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--52.Vision services [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--53.Dental services [REVOKED]
[Revoked 6-25-06]

317:30⊂chapter=3∂=3--54.Hearing services [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--55.Periodic and interperiodic screening examinations [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--56.Partial screening examination [REVOKED]
[Revoked 06-25-06]

317:30⊂chapter=3∂=3--57.General SoonerCare coverage - categorically needy
[Revised 09-14-18]

The following are general SoonerCare coverage guidelines for the categorically needy:

(1) Inpatient hospital services other than those provided in an institution for mental diseases.

(A) Adult coverage for inpatient hospital stays as described at OAC 317:30-5-41.

(B) Coverage for members under twenty-one (21) years of age is not limited. All admissions must be medically necessary. All psychiatric admissions require prior authorization for an approved length of stay.

(2) Emergency department services.

(3) Dialysis in an outpatient hospital or free standing dialysis facility.

(4) Outpatient therapeutic radiology or chemotherapy for proven malignancies or opportunistic infections.

(5) Outpatient surgical services - facility payment for selected outpatient surgical procedures to hospitals which have a contract with the Oklahoma Health Care Authority (OHCA).

(6) Outpatient mental health services for medical and remedial care including services provided on an outpatient basis by certified hospital based facilities that are also qualified mental health clinics.

(7) Rural health clinic services and other ambulatory services furnished by rural health clinic.

(8) Optometrists' services - only as listed in Subchapter 5, Part 45, Optometrist specific rules of this Chapter.

(9) Maternity clinic services.

(10) Outpatient diagnostic x-rays and lab services. Other outpatient services provided to adults, not specifically addressed, are covered only when prior authorized by the agency's Medical Authorization Unit.

(11) Medically necessary screening mammography. Additional follow-up mammograms are covered when medically necessary.

(12) Nursing facility services (other than services in an institution for tuberculosis or mental diseases).
(13) Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) are available for members under twenty-one (21) years of age to provide access to regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth. Federal regulations also require that diagnosis and treatment be provided for conditions identified during a screening whether or not they are covered under the State Plan, as long as federal funds are available for these services. These services must be necessary to ameliorate or correct defects and physical or mental illnesses or conditions and require prior authorization. EPSDT/OHCA Child Health services are outlined in OAC 317:30-3-65.2 through 317:30-3-65.4.

(A) Child health screening examinations for eligible children by a medical or osteopathic physician, physician assistant, or advanced practice nurse practitioner.

(B) Diagnostic x-rays, lab, and/or injections when prescribed by a provider.

(C) Immunizations.

(D) Outpatient care.

(E) Dental services as outlined in OAC 317:30-3-65.8.

(F) Optometrists' services. The EPSDT periodicity schedule provides for at least one (1) visual screening and glasses each twelve (12) months. In addition, payment is made for glasses for children with congenital aphakia or following cataract removal. Interperiodic screenings and glasses at intervals outside the periodicity schedule for optometrists are allowed when a visual condition is suspected. Payment is limited to two (2) glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.

(G) Hearing services as outlined in OAC 317:30-3-65.9.

(H) Prescribed drugs.

(I) Outpatient psychological services as outlined in OAC 317:30-5-275 through 317:30-5-278.

(J) Inpatient psychiatric services as outlined in OAC 317:30-5-95 through 317:30-5-97.

(K) Transportation. Provided when necessary in connection with examination or treatment when not otherwise available.

(L) Inpatient hospital services.

(M) Medical supplies, equipment, appliances and prosthetic devices beyond the normal scope of SoonerCare.

(N) EPSDT services furnished in a qualified child health center.

(14) Family planning services and supplies for members of child-bearing age, including counseling, insertion of intrauterine device, implantation of subdermal contraceptive device, and sterilization for members twenty-one (21) years of age and older who are legally competent, not institutionalized and have signed the "Consent Form" at least thirty (30) days prior to procedure. Reversal of sterilization procedures for the purposes of conception is not covered. Reversal of sterilization procedures are covered when medically indicated and substantiating documentation is attached to the claim.

(15) Physicians' services whether furnished in the office, the member's home, a hospital, a nursing facility,Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), or elsewhere. For adults, payment is made for compensable hospital days described at OAC 317:30-5-41. Office visits for adults are limited to four (4) per month except when in connection with conditions as specified in OAC 317:30-5-9(b).

(16) Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law. See applicable provider section for limitations to covered services for:

(A) Podiatrists' services

(B) Optometrists' services

(C) Psychologists' services

(D) Certified Registered Nurse Anesthetists

(E) Certified Nurse Midwives

(F) Advanced Practice Nurses

(G) Anesthesiologist Assistants

(17) Free-standing ambulatory surgery centers.

(18) Prescribed drugs not to exceed a total of six (6) prescriptions with a limit of two (2) brand name prescriptions per month. Exceptions to the six (6) prescription limit are:

(A) unlimited medically necessary monthly prescriptions for:

(i) members under the age of twenty-one (21) years; and

(ii) residents of nursing facilities or ICF/IID.

(B) seven (7) medically necessary generic prescriptions per month in addition to the six (6) covered under the State Plan (including three (3) brand name prescriptions) are allowed for adults receiving services under the 1915(c) Home and Community Based Services Waivers (HCBS). These additional medically necessary prescriptions beyond the three (3) brand name or thirteen (13) total prescriptions are covered with prior authorization.

(19) Rental and/or purchase of durable medical equipment.

(20) Adaptive equipment, when prior authorized, for members residing in private ICF/IID's.

(21) Dental services for members residing in private ICF/IID's in accordance with the scope of dental services for members under age twenty-one (21).

(22) Prosthetic devices limited to catheters and catheter accessories, colostomy and urostomy bags and accessories, tracheostomy accessories, nerve stimulators, hyperalimentation and accessories, home dialysis equipment and supplies, external breast prostheses and support accessories, oxygen/oxygen concentrator equipment and supplies, respirator or ventilator equipment and supplies, and those devices inserted during the course of a surgical procedure.

(23) Standard medical supplies.

(24) Eyeglasses under EPSDT for members under age twenty-one (21). Payment is also made for glasses for children with congenital aphakia or following cataract removal. Payment is limited to two (2) glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.

(25) Blood and blood fractions for members when administered on an outpatient basis.

(26) Inpatient services for members age sixty-five (65) or older in institutions for mental diseases, limited to those members whose Medicare, Part A benefits are exhausted for this particular service and/or those members who are not eligible for Medicare services.

(27) Nursing facility services, limited to members preauthorized and approved by OHCA for such care.

(28) Inpatient psychiatric facility admissions for members under twenty-one (21) are limited to an approved length of stay effective July 1, 1992, with provision for requests for extensions.

(29) Transportation and subsistence (room and board) to and from providers of medical services to meet member's needs (ambulance or bus, etc.), to obtain medical treatment.

(30) Extended services for pregnant women including all pregnancy-related and postpartum services to continue to be provided, as though the women were pregnant, for sixty (60) days after the pregnancy ends, beginning on the last date of pregnancy.

(31) Nursing facility services for members under twenty-one (21) years of age.

(32) Personal care in a member's home, prescribed in accordance with a plan of treatment and rendered by a qualified person under supervision of a Registered Nurse (RN).

(33) Part A deductible and Part B Medicare Coinsurance and/or deductible.

(34) HCBS for the intellectually disabled.

(35) Home health services limited to thirty-six (36) visits per year and standard supplies for one (1) month in a twelve (12) month period. The visits are limited to any combination of RN and nurse aide visits, not to exceed thirty-six (36) per year.

(36) Medically necessary solid organ and bone marrow/stem cell transplantation services for children and adults are covered services based upon the conditions listed in (A)-(D) of this paragraph:

(A) Transplant procedures, except kidney and cornea, must be prior authorized to be compensable.

(B) To be prior authorized all procedures are reviewed based on appropriate medical criteria.

(C) To be compensable under the SoonerCare program, all transplants must be performed at a facility which meets the requirements contained in Section 1138 of the Social Security Act.

(D) Finally, procedures considered experimental or investigational are not covered.

(37) HCBS for intellectually disabled members who were determined to be inappropriately placed in a nursing facility (Alternative Disposition Plan - ADP).

(38) Case management services for the chronically and/or severely mentally ill.

(39) Emergency medical services including emergency labor and delivery for illegal or ineligible aliens.

(40) Services delivered in Federally Qualified Health Centers. Payment is made on an encounter basis.

(41) Early intervention services for children ages zero (0) to three (3).

(42) Residential behavior management in therapeutic foster care setting.

(43) Birthing center services.

(44) Case management services through the Oklahoma Department of Mental Health and Substance Abuse Services.

(45) HCBS for aged or physically disabled members.

(46) Outpatient ambulatory services for members infected with tuberculosis.

(47) Smoking and tobacco use cessation counseling for children and adults.

(48) Services delivered to American Indians/Alaskan Natives in I/T/Us. Payment is made on an encounter basis.

(49) OHCA contracts with designated agents to provide disease state management for individuals diagnosed with certain chronic conditions. Disease state management treatments are based on protocols developed using evidence-based guidelines.

317:30⊂chapter=3∂=3--58.General Medicaid coverages - medically needy [REVOKED]
[Revoked 7-1-03]

317:30⊂chapter=3∂=3--59.General program exclusions - adults
[Revised 09-01-16]

The following are excluded from SoonerCare coverage for adults:

(1) Inpatient admission for diagnostic studies that could be performed on an outpatient basis.

(2) Services or any expense incurred for cosmetic surgery.

(3) Services of two physicians for the same type of service to the same member on the same day, except when supplemental skills are required and different specialties are involved.

(4) Refractions and visual aids.

(5) Pre-operative care within 24 hours of the day of admission for surgery and routine post-operative care as defined under the global surgery guidelines promulgated by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS).

(6) Sterilization of members who are under 21 years of age, mentally incompetent, or institutionalized or reversal of sterilization procedures for the purposes of conception.

(7) Non-therapeutic hysterectomies.

(8) Induced abortions, except when certified in writing by a physician that the abortion was necessary due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed, or that the pregnancy is the result of an act of rape or incest. (Refer to OAC 317:30-5-6 or 317:30-5-50.)

(9) Medical services considered experimental or investigational.

(10) Services of a Certified Surgical Assistant.

(11) Services of a Chiropractor. Payment is made for Chiropractor services on Crossover claims for coinsurance and/or deductible only.

(12) Services of an independent licensed Physical and/or Occupational Therapist.

(13) Services of a Psychologist.

(14) Services of an independent licensed Speech and Hearing Therapist.

(15) Payment for more than four outpatient visits per month (home or office) per member, except those visits in connection with family planning or related to emergency medical conditions.

(16) Payment for more than two nursing facility visits per month.

(17) More than one inpatient visit per day per physician.

(18) Payment for removal of benign skin lesions.

(19) Physician services which are administrative in nature and not a direct service to the member including such items as quality assurance, utilization review, treatment staffing, tumor board review or multidisciplinary opinion, dictation, and similar functions.

(20) Charges for completion of insurance forms, abstracts, narrative reports or telephone calls.

(21) Payment for the services of social workers, licensed family counselors, registered nurses or other ancillary staff, except as specifically set out in OHCA rules.

(22) Mileage.

(23) A routine hospital visit on the date of discharge unless the member expired.

(24) Direct payment to perfusionist as this is considered part of the hospital reimbursement.

(25) Inpatient chemical dependency treatment.

(26) Fertility treatment.

(27) Payment to the same physician for both an outpatient visit and admission to hospital on the same date.

(28) Sleep studies. 

317:30⊂chapter=3∂=3--60.General program exclusions - children
[Revised 06-25-11]
(a) The following are excluded from SoonerCare coverage for children:
(1) Inpatient admission for diagnostic studies that could be performed on an outpatient basis.
(2) Services or any expense incurred for cosmetic surgery unless the physician certifies the procedure emotionally necessary.
(3) Services of two physicians for the same type of service to the same member on the same day, except when supplemental skills are required and different specialties are involved.
(4) Pre-operative care within 24 hours of the day of admission for surgery and routine post-operative care as defined under the global surgery guidelines promulgated by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS).
(5) Sterilization of members who are under 21 years of age, mentally incompetent, or institutionalized or reversal of sterilization procedures for the purposes of conception.
(6) Non-therapeutic hysterectomies.
(7) Induced abortions, except when certified in writing by a physician that the abortion was necessary due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed, or that the pregnancy is the result of an act of rape or incest. (See OAC 317:30-5-6 or 317:30-5-50).
(8) Medical services considered experimental or investigational.
(9) Services of a Certified Surgical Assistant.
(10) Services of a Chiropractor.
(11) More than one inpatient visit per day per physician.
(12) Payment to the same physician for both an outpatient visit and admission to hospital on the same date.
(13) Physician services which are administrative in nature and not a direct service to the member including such items as quality assurance, utilization review, treatment staffing, tumor board review or multidisciplinary opinion, dictation, and similar functions.
(14) Payment for the services of social workers, licensed family counselors, registered nurses or other ancillary staff, except as specifically set out in OHCA rules.
(15) Direct payment to perfusionist as this is considered part of the hospital reimbursement.
(16) Charges for completion of insurance forms, abstracts, narrative reports or telephone calls.
(17) Mileage.
(18) A routine hospital visit on date of discharge unless the member expired.
(b) Not withstanding the exclusions listed in (1)-(18) of subsection (a), the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) provides for coverage of needed medical services normally outside the scope of the medical program when performed in connection with an EPSDT screening and prior authorized.
317:30⊂chapter=3∂=3--61.Self-Directed Services
[Issued 12-03-09]
(a) Agency Model. The OHCA Self-Direction Model is an overarching set of guidelines to standardize policy for all self-directed service programs operated through the SoonerCare program. The following rules set forth minimum requirements to which all self-directed service programs must adhere.   As the infrastructure for new or renewing self-direction programs is developed, the following elements will serve as a template for the programs to follow. 
(b) Definitions.
(1) "Financial Management Service" (FMS) is defined as a fiscal intermediary that provides at a minimum, accounting, billing and payroll services on behalf of the member, for reimbursement through the OHCA.
(2) "Program" is defined as a set of benefits offered to a specific population of SoonerCare members (the program can be operated by the OHCA or another agency partner).
(3) "Rendering provider" is defined as the actual deliverer of allowable goods or services.
(4) "Self-Direction" is defined as a method of service delivery that allows members to determine what supports and services they need to live successfully in a home and community based setting.
(c) Member processes. The program will establish, at a minimum, the following processes for members who choose to self direct:
(1)The program will establish requirements for member eligibility including a process for evaluating member needs. These requirements will also include a process for denial of eligibility.
(2) The program will determine detailed benefit packages and will specify allowable goods and services available to members.
(3) The program will define the member's options for self-direction. These will vary according to the approved benefit package. At a minimum, the options for self-direction will include:
(A) training for members that is appropriate to the care provided;
(B) utilization of a Financial Management Service (FMS) for purposes of payroll and payment to vendors. The FMS may also provide other services as determined by the individual program;
(C) detailed description demonstrating that members have freedom of choice under all levels of self-direction options offered;
(D) for security and auditing purposes, the program will design and implement a system for verification of services in accordance with CMS standards; and
(E) designate methods of outreach to inform members and potential members of available services, emergency procedures, concerns and general information.
(d) Provider processes. The program will establish minimum criteria for providers. These criteria will be specific to provider type and at a minimum include:
(1) training appropriate to each level of service to be provided;
(2) credentialing or licensure by a recognized state agency, if applicable to the provider type and duties;
(3) establish and specify an appropriate provider type and specialty code to apply to approved providers for the program. This provider type and specialty code must meet requirements for data integrity and auditing purposes.
(4) specify the minimum and maximum allowed rates for providers by provider type. Rates will be governed by guidelines determined by the program within approved limits and budget allowances. The program will also establish an appropriate methodology for fees paid to the FMS for administration of payroll, accounting and any other contracted duties;
(5) provider contracts with the OHCA or with a contracted agency operating as an Organized Health Care Delivery System (OHCDS);
(6) establish a provider enrollment process. At a minimum, the process shall include the following:
(A) all rendering providers will be entered into the OHCA provider tracking system and given a unique rendering provider ID number. In instances of an Organized Health Care Delivery System, the OHCDS will be considered the rendering provider for purposes of enrollment.
(B) the FMS will be entered into the OHCA provider tracking system and given a unique provider ID number as the billing or group provider;
(C) all rendering providers must pass a background investigation prior to employment.
(e) Provider selection & outreach.
(1) The program will identify methods for assisting members in provider selection.
(2) The program will determine processes for informing and recruiting providers.
(3) The program will develop processes for provider communication to inform providers of procedures, concerns and general information.
(f) Claims filing process.
(1) The program will ensure claims are billed to the OHCA from the FMS and processed through the OHCA claims tracking system. 
(2) The program will have appropriate procedure codes with necessary modifiers for each benefit in the program.
(3) Procedure codes must provide sufficient detail to allow for claims identification in the OHCA claims tracking system (all claims must have at a minimum a billing, rendering and pay to).
(g) Claims payment processes for providers, agents and agencies. Payments for rendering providers must be paid through an FMS. The program will establish the payment options for the FMS to utilize for paying the rendering providers.
(h) Payment processes for alternative goods & services. Some programs may allow for non-traditional services and alternative sources for goods with approval. The program shall determine the process for the payment of these alternative benefits with the following restrictions:
(1) identify appropriate procedure codes with necessary modifiers to allow claims to be processed and identified in the OHCA claims tracking system;
(2) prior authorization for alternative goods and services and payment made directly to the vendor. No payment for good or services will be made to the member.
317:30⊂chapter=3∂=3--62.Serious reportable events - never events
[Revised 04-01-10]
(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.
(1) "Surgical and other invasive procedures" are defined as operative procedures in which skin or mucous membranes and connective tissues are incised or an instrument is introduced through a natural body orifice. Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation. They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization. They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar. They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.
(2) A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that member.
(3) A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that member including surgery on the right body part, but on the wrong location on the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine).
(4) A surgical or other invasive procedure is considered to have been performed on the wrong member if that procedure is not consistent with the correctly documented informed consent for that member.
(b) Coverage. The Oklahoma Health Care Authority (OHCA) will no longer cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs (1) a different procedure altogether; (2) the correct procedure but on the wrong body part; or (3) the correct procedure but on the wrong member. SoonerCare will not cover hospitalizations or any services related to these non-covered procedures. All services provided in the operating room when an error occurs are considered related and therefore not covered. All providers in the operating room when the error occurs, who could bill individually for their services, are also not eligible for payment. All related services provided during the same hospitalization in which the error occurred are not covered. A provider cannot shift financial liability or responsibility for the non-covered services to the member if the OHCA has determined that the service is related to one of the above erroneous surgical procedures.
(c) Billing. For inpatient claims, hospitals are required to bill two claims when the erroneous surgery is reported, one claim with covered services or procedures unrelated to the erroneous surgery, the other claim with the non-covered services or procedures as a no-payment claim. For outpatient and practitioner claims, providers are required to append the applicable HCPCS modifiers to all lines related to the erroneous surgery. Claim lines submitted with one of the applicable HCPCS modifiers will be line-item denied.
(d) Related claims. Once a claim for the erroneous surgery(s) has been received, OHCA may review member history for related claims as appropriate. Incoming claims for the identified member may be reviewed for an 18-month period from the date of the surgical error. If such claims are identified to be related to the erroneous surgical procedure(s), OHCA may take appropriate action to deny such claims and recover any overpayments on claims already processed.
(e) Dually eligible members. SoonerCare will not act as a secondary payer for Medicare non-payment of the aforementioned erroneous surgery(s).
(f) Hospital acquired conditions. SoonerCare will not reimburse the extra cost of treating certain categories of conditions that occur while a member is in the hospital. See OAC 317:30-3-63 for specific information regarding hospital acquired conditions.

 

317:30⊂chapter=3∂=3--63.Hospital acquired conditions
[Issued 04-01-10]
(a) Coverage. The Oklahoma Health Care Authority (OHCA) will no longer reimburse the extra cost of treating certain categories of conditions that occur while a member is in the hospital. For discharges, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. The claim will be grouped to a DRG as if the diagnosis was not present on the claim. The selected conditions that OHCA recognizes are those conditions identified as non-payable by Medicare. OHCA may revise through addition or deletion the selected conditions at any time during the fiscal year. The following is a complete list of the hospital acquired conditions (HACs) currently recognized by OHCA:
(1) Foreign Object Retained After Surgery
(2) Air Embolism
(3) Blood Incompatibility
(4) Pressure Ulcer Stages III & IV
(5) Falls and Trauma
(A) Fracture
(B) Dislocation
(C) Intracranial Injury
(D) Crushing Injury
(E) Burn
(F) Electric Shock
(6) Catheter-Associated Urinary Tract Infection
(7) Vascular Catheter-Associated Infection
(8) Manifestations of Poor Glycemic Control
(A) Diabetic Ketoacidosis
(B) Nonketotic Hyperosmolar Coma
(C) Hypoglycemic Coma
(D) Secondary Diabetes with Ketoacidosis
(E) Secondary Diabetes with Hyperosmolarity
(9) Surgical Site Infection Following:
(A) Coronary Artery Bypass Graft- Mediastinitis
(B) Bariatric Surgery
(i) Laparoscopic Gastric Bypass
(ii) Gastroenterostomy
(iii) Laparoscopic Gastric Restrictive Surgery
(C) Orthopedic Procedures
(i) Spine
(ii) Neck
(iii) Shoulder
(iv) Elbow
(10) Deep Vein Thrombosis and Pulmonary Embolism
(A) Total Knee Replacement
(B) Hip Replacement
(b) Billing. Hospitals paid under the diagnosis related grouping (DRG) methodology are required to submit a present on admission (POA) indicator for the principal diagnosis code and every secondary diagnosis code for all discharges. A valid POA indicator is required on all inpatient hospital claims. Claims with no valid POA indicator will be denied. For all claims involving inpatient admissions, OHCA will group diagnoses into the proper DRG using the POA indicator. 
(c) Dually eligible members. SoonerCare will not act as a secondary payer for Medicare non-payment of the aforementioned hospital acquired conditions.

 

317:30⊂chapter=3∂=3--64.Payment for lodging and meals

[Revised 09-01-15]

(a)  Payment for lodging and/or meals assistance for an eligible member and/or an approved medical escort is provided only when medically necessary in connection with transportation to and from SoonerCare compensable services. The member and/or medical escort must make a reasonable effort to secure lodging at a hospital or non-profit organization. The Oklahoma Health Care Authority (OHCA) has discretion and final authority to approve or deny any lodging and/or meal services. 

(1) Lodging and/or meals are reimbursable when prior approved. Payment for lodging and/or meals is limited to a period of up to 24 hours prior to the start of member's medical services and up to 24 hours after the services end. Lodging is approved for the member and/or one approved medical escort. The following factors may be considered by the OHCA when approving reimbursement for a member and/or one medical escort:

(A) travel is to obtain specialty care; and

(B) the trip cannot be completed during SoonerRide operating hours; and/or

(C) the trip is 100 miles or more from the member's residence, as listed in the OHCA system, to the medical facility; and/or

(D) the member's medical treatment requires an overnight stay, or the condition of the member discourages traveling.

(2) When a member is not required to have a PCP or when a PCP referral is not required to obtain a SoonerCare covered service, a member may go to any provider they choose but SoonerCare will not reimburse for transportation, lodging, or meals if the distance is beyond what is considered the nearest appropriate facility.

(3) Meals will be reimbursed if lodging criteria is met. Duration of the trip must be 18 hours or greater.

(4) Reimbursement for meals is based on a daily per diem and may be used for breakfast, lunch or dinner, or all three meals, whichever is required.

(5) During inpatient or outpatient medical stays, lodging and/or meals services are reimbursed for a period of up to 14 days without prior approval; stays exceeding the 14 day period must be prior approved. A member may not receive reimbursement for lodging and/or meals services for days the member is an inpatient in a hospital or medical facility.

(6) For eligible members in the Neonatal Intensive Care Unit (NICU) a minimum visitation of 6 hours per day for the approved medical escort is required for reimbursement of lodging and/or meals services. Non-emergency transportation services for medically necessary visitation may be provided for eligible medical escorts. 

(b) Lodging must be with a SoonerCare contracted Room and Board provider, when available, before direct reimbursement to a member and/or medical escort can be approved. If lodging and/or meals assistance with contracted Room and Board providers are not available, the member and/or medical escort may request reimbursement assistance by submitting the appropriate travel reimbursement forms. The travel reimbursement forms may be obtained by contacting SoonerCare Care Management division. Any lodging and/or meal expenses claimed on the travel reimbursement forms must be documented with the required receipts and medical records to document the lodging criteria have been met. Reimbursement must not exceed state per diem amounts. The OHCA has discretion and the final authority to approve or deny lodging and/or meals reimbursement.

(c) Payment for transportation and lodging and/or meals of one medical escort may be approved if the service is required.

(d) If the Oklahoma Department of Human Services (OKDHS) removes a child from his/her home, a court must appoint a temporary guardian. During this time the temporary guardian is eligible for medical escort related lodging and/or meals services. It is the responsibility of the OHCA to determine this necessity. The decision should be based on the following circumstances:

(1) when the individual's health or disability does not permit traveling alone; and
(2) when the individual seeking medical services is a minor child.

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.