OHCA Policies and Rules

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Part       CERTIFIED LABORATORIES

317:30⊂chapter=5∂=7--100.Eligible providers
[Revised 02-04-10]
Reimbursement for lab services is made in accordance with the Clinical Laboratory Improvement Amendment of 1988 (CLIA). These regulations provide that payment may be made only for services furnished by a laboratory that meets CLIA conditions, including those furnished in physicians' offices. Regulations specify that any and every facility which tests human specimens for the purpose of providing information for the diagnosis, prevention, or treatment of any disease, or impairment of, or the assessment of the health of human beings is subject to CLIA. All facilities which perform these tasks must make application for certification by CMS. Eligible SoonerCare providers must be certified under the CLIA program and have obtained a CLIA ID number from CMS and have a current contract on file with the OHCA.
317:30⊂chapter=5∂=7--101.Coverage for adults
[Revised 7-01-99]
Payment is made to certified laboratories for medically necessary services to adults as set forth in this Section.
(1) Inpatient services.
(A) Claims for inpatient anatomical pathology must be billed by the individual pathologist performing the examination.
(B) Inpatient consultations by Pathologists are compensable. Claim form must include referring physician, diagnosis, and test(s) for which the consultation was requested.
(2) Outpatient services. Payment is made for medically necessary outpatient services:

317:30⊂chapter=5∂=7--102.Coverage for children
[Issued 1-05-95]
Coverage of laboratory services for children is as follows:
(1) Inpatient services.
(A) Claims for inpatient anatomical pathology must be billed by the individual pathologist performing the examination.
(B) Inpatient pathology consultations are compensable. Claim form must include referring physician, diagnosis and test(s) for which the consultation was requested.
(2) Outpatient services.
(A) Outpatient clinical laboratory services are covered when performed in conjunction with an Early and Periodic Screening Diagnosis and Treatment EPSDT) examination. The claim must be documented with name of attending physician.
(B) Medically necessary outpatient clinical laboratory services provided in conjunction with physician office visits are compensable under EPSDT.

317:30⊂chapter=5∂=7--103.Vocational rehabilitation
[Issued 1-05-95]
Payment is made for those vocational rehabilitation services which are preauthorized by the patient's counselor.

317:30⊂chapter=5∂=7--104.Individuals eligible for Part B of Medicare
[Revised 7-1-02]
Payment is made utilizing the Medicaid allowable for comparable services.

317:30⊂chapter=5∂=7--105.Non-covered procedures
[Issued 1-05-95]
The following procedures by certified laboratories are not covered:
(1) Tissue examinations of teeth and foreign objects.
(2) Tissue examination of lens after cataract surgery except when the patient is under 21 years of age.
(3) Charges for autopsy.
(4) Hair analysis for trace metal analysis.
(5) Procedures deemed experimental or investigational.
(6) Professional component charges for inpatient clinical laboratory services.
(7) Inpatient clinical laboratory services.

317:30⊂chapter=5∂=7--106.Payment rates

[Revised 09-12-14]
   Payment will be made for covered clinical laboratory services in accordance with methodology approved under the Oklahoma Medicaid State Plan.

317:30⊂chapter=5∂=7--107.Claim form [REVOKED]
[Revoked 6-27-02]

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.