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Part       MEDICAL SUPPLIERS

317:30⊂chapter=5∂=17--210.Eligible providers
[Revised 09-01-16]

All eligible medical suppliers must have a current contract with the Oklahoma Health Care Authority. The supplier must comply with all applicable State and Federal laws. Effective January 1, 2011, all suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must be accredited by a Medicare deemed accreditation organization for quality standards for DMEPOS suppliers in order to bill the SoonerCare program. OHCA may make exceptions to this standard based on the exemptions provided by the Centers for Medicare and Medicaid Services (CMS) for Medicare accreditation, if the provider is a government-owned entity, or at a provider's request and at the discretion of OHCA based on access issues and/or agency needs for SoonerCare members. Additionally, unless an exception is granted from the OHCA, all DMEPOS providers must meet the following criteria:

(1) DMEPOS providers are required to have a physical location in the State of Oklahoma, or within a designated range of the Oklahoma State border, as determined by the OHCA. The OHCA may make exceptions to this requirement if a DMEPOS provider provides a specialty item, product, or service, which is not otherwise available to SoonerCare members within the State of Oklahoma. Provider contracts for out-of-state DMEPOS providers will be reviewed on a case-by-case basis for specialty items only. The OHCA has discretion and the final authority to approve or deny any provider contract.

(2) DMEPOS providers are required to comply with Medicare DMEPOS Supplier Standards for DMEPOS provided to SoonerCare members, except the requirement to meet surety bond requirements, as specified in 42 C.F.R. 424.57(c).

(3) Complex Rehabilitation Technology (CRT) suppliers are considered DMEPOS providers. Only CRT suppliers may bill CRT procedure codes. A CRT supplier means a company or entity that:

(A) Is accredited by a recognized accrediting organization as a supplier of CRT;

(B) Is an enrolled Medicare supplier and meets the supplier and quality standards established for DME suppliers, including those for CRT, under the Medicare program;

(C) Employs as a W-2 employee at least one qualified CRT professional for each location to:

(i) Analyze the needs and capacities of complex-needs patients in consultation with qualified health care professionals;

(ii) Participate in selecting appropriate CRT items for such needs and capacities; and

(iii) Provide the complex-needs patient technology related training in the proper use and maintenance of the CRT items.

(D) Requires a qualified CRT professional be physically present for the evaluation and determination of the appropriate CRT;

(E) Has the capability to provide service and repair by qualified technicians for all CRT items it sells; and

(F) Provides written information to the complex-needs patient prior to ordering CRT as to how to access service and repair.

317:30⊂chapter=5∂=17--210.1.Coverage for adults

[Issued 12-03-09]
Coverage of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for adults is specified in OAC 317:30-5-211.1 through OAC 317:30-5-211.18.

317:30⊂chapter=5∂=17--210.2.Coverage for children
[Revised 09-01-16]

(a) Coverage. Coverage of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for children includes the specified coverage for adults found in OAC 317:30-5-211.1 through OAC 317:30-5-211.18. In addition the following are covered items for children only:

(1) Orthotics and prosthetics.

(2) Enteral nutrition is considered medically necessary for certain conditions in which, without the products, the member's condition would deteriorate to the point of severe malnutrition.

(A) Enteral nutrition must be prior authorized. PA requests must include:

(i) the member's diagnosis;

(ii) the impairment that prevents adequate nutrition by conventional means;

(iii) the member's weight history before initiating enteral nutrition that demonstrates oral intake without enteral nutrition is inadequate;

(iv) the percentage of the member's average daily nutrition taken by mouth and by tube; and

(v) prescribed daily caloric intake.

(B) Enteral nutrition products that are administered orally and related supplies are not covered.

(3) Continuous positive airway pressure devices (CPAP).

(b) EPSDT. Services deemed medically necessary and allowable under federal regulations may be covered by the EPSDT Child Health program even though those services may not be part of the SoonerCare program.  These services must be prior authorized.

(c) Medical necessity. Federal regulations require OHCA to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or that are considered experimental.

317:30⊂chapter=5∂=17--211.Coverage for adults
[Revoked 07-01-07]

317:30⊂chapter=5∂=17--211.1.Definitions
[Revised 09-01-16]

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

"Adaptive equipment" means devices, aids, controls, appliances or supplies of either a communication or adaptive type, determined necessary to enable the person to increase his or her ability to function in a home and community based setting or private Intermediate Care Facilities for Individuals with Intellectual Disabilities (IFC/IID) with independence and safety.

"Basic activities of daily living" means a series of activities performed on a day-to-day basis that are necessary to care for oneself (e.g., personal hygiene, dressing, eating, maintaining continence and transferring).

"Capped rental" means monthly payments for the use of the Durable Medical Equipment (DME) for a limited period of time not to exceed 13 months. Items are considered purchased after 13 months of continuous rental.

"Certificate of medical necessity (CMN)" means a certificate required to help document the medical necessity and other coverage criteria for selected items. Those items are defined in this Chapter. The physician's certification must include the member's diagnosis, the reason the equipment is required, and the physician's estimate, in months, of the duration of its need.

"Complex-needs patient"means an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities.

"Complex rehabilitation technology" means medically necessary durable medical equipment and items that are individually configured to meet specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living of a complex needs patient. Such equipment and items include, but are not limited to, individually configured power wheelchairs and accessories, individually configured manual wheelchairs and accessories, adaptive seating and positioning systems and accessories, and other specialized equipment such as standing frames and gait trainers.

"Customized DME" means items of DME which have been uniquely constructed or substantially modified for a specific member according to the description and orders of the member's treating physician or other qualified medical professional. For instance, a wheelchair would be considered "customized" if it has been:

(A) measured, fitted, or adapted in consideration of the the member's body size, disability, period of need, or intended use;

(B) assembled by a supplier or ordered from a manufacturer who makes available customized features, modifications, or components for wheelchairs; and

(C) intended for an individual member's use in accordance with instructions from the member's physician.

"Durable medical equipment (DME)" means equipment that can withstand repeated use (e.g. a type of item that could normally be rented), is used to serve a medical purpose, is not useful to a person in the absence of an illness or injury, and is used in the most appropriate setting, including the home or workplace.

"Instrumental activities of daily living"means activities thatare not necessarily required on a daily basis, but are important to being able to live independently (e.g., basic communication skills, transportation, meal preparation, shopping, housework, managing medication and managing personal finances).

"Invoice" means a document that provides the following information when applicable: the description of product, quantity, quantity in box, purchase price, NDC, strength, dosage, provider, seller's name and address, purchaser's name and address, and date of purchase. At times, visit notes will be required to determine how much of the supply was expended. When possible, the provider should identify the SoonerCare member receiving the equipment or supply on the invoice.

"Medical supplies" means an article used in the cure, mitigation, treatment, prevention, or diagnosis of illnesses. Disposable medical supplies are medical supplies consumed in a single usage and do not include skin care creams or cleansers. Medical supplies do not include surgical supplies or medical or surgical equipment.

"OHCA CMN" means a certificate required to help document the medical necessity and other coverage criteria for selected items. Those items are defined in this chapter. The physician's certification must include the member's diagnosis, the reason equipment is required, and the physician's estimate, in months, of the duration of its need. This certificate is used when the OHCA requires a CMN and one has not been established by CMS.

"Orthotics" means an item used for the correction or prevention of skeletal deformities.

   "Prosthetic devices" means a replacement, corrective, or supportive device (including repair and replacement parts of the same) worn on or in the body to artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or support a weak or deformed portion of the body.

   "Qualified complex rehabilitation technology professional" means an individual who is certified as an Assistive Technology Professional (ATP) by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

317:30⊂chapter=5∂=17--211.2.Medical necessity
[Revised 05-11-12]
(a) Coverage. Coverage is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member. The member's diagnosis must warrant the type of equipment or supply being purchased or rented.
(b) Prescription requirements. All DME, except for equipment repairs with a cost per item of less than $250.00 total parts and labor and hearing aid batteries, require a prescription signed by a physician, a physician assistant, or an advanced practice nurse. Except as otherwise stated in state or federal law, the prescription must be in writing, or given orally and later reduced to writing by the provider filling the order. Prescriptions are valid for no more than one year from the date written. The prescription must include the following information:
(1) date of the order;
(2) name and address of the prescriber;
(3) name and address of the member;
(4) name or description and quantity of the prescribed item;
(5) diagnosis for the item requested;
(6) directions for use of the prescribed item; and
(7) prescriber's signature.
(c) Certificate of medical necessity. For certain items or services, the supplier must receive a signed CMN/OHCA CMN from the treating physician. The supplier must have a signed CMN/OHCA CMN in their records before they submit a claim for payment. The CMN/OHCA CMN may be faxed, copied or the original hardcopy.
(d) Place of service.
(1) OHCA covers DMEPOS for use in the member's place of residence except if the member's place of residence is a nursing facility.
(2) For members residing in a nursing facility, most medical supplies and/or DME are considered part of the facility's per diem rate. Refer to coverage for nursing facility residents at OAC 317:30-5-211.16.
317:30⊂chapter=5∂=17--211.3.Prior authorization (PA)

[Revised 09-01-15]
(a) General. Prior authorization is the electronic or written authorization issued by OHCA to a provider prior to the provision of a service. Providers should obtain a PA before providing services.
(
b) Requirements. Billing must follow correct coding guidelines as promulgated by CMS or per uniquely and publicly promulgated OHCA guidelines. DME claims must include the most appropriate HCPCS code as assigned by the Medicare Pricing, Data, Analysis, and Coding (PDAC) or its successor.  Authorizations for services not properly coded will be denied.  The following services require prior authorization:

(1) services that exceed quantity/frequency limits;

(2) medical need for an item that is beyond OHCA's standards of coverage;

(3) use of a Not Otherwise Classified (NOC) code or miscellaneous codes;

(4) services for which a less costly alternative may exist; and

(5) procedures indicating that a PA is required on the OHCA fee schedule.

(c) Prior authorization requests. Refer to OAC 317:30-5-216.

317:30⊂chapter=5∂=17--211.4.Rental and/or purchase
[Revised 09-01-15]

(a) Purchase(New or Used). Items may be purchased if they are inexpensive accessories for other DME or the equipment itself will be used for an extended period of time. The OHCA reserves the right to determine whether items of DMEPOS will be rented or purchased.

(b) Rental.

(1) Continuous rental. Items that require regular and ongoing servicing/maintenance are rented for the duration indicated by the physician's order and medical necessity. Examples include, but are not limited to, oxygen and volume ventilators. The rental payment includes routine servicing and all necessary repairs or replacements to make the rented item functional.

(2) Capped rental. Items are rented until the purchase price is reached. Capped rental items may be rented for a maximum of 13 months. If the member changes suppliers during or after the 13th continuous month rental period, this does not result in a new rental period. The supplier that provides the item to the member the 13th month of rental is responsible for supplying the equipment, as well as routine maintenance and servicing after the 13th month. If used equipment is issued to the member, the usual and customary charge reported to the OHCA must accurately reflect that the item is used.

(c) Converting rental to purchase. The majority of DME can be rented as a capped rental for up to a maximum of 13 continuous months. When an item is converted to a purchase during the rental period, the provider must subtract the amount already paid for the rental item from the total purchase price.
317:30⊂chapter=5∂=17--211.5.Repairs, maintenance, replacement and delivery
[Revised 09-01-15]

(a) Repairs. Repairs to equipment that a member owns are covered when they are necessary to make the equipment usable. The repair charge includes the use of "loaner" equipment as required. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, payment cannot be made for the amount in excess. Repairs of rented equipment are not covered.

(b) Maintenance. Routine periodic servicing, such as testing, cleaning, regulating, and checking the member's equipment is considered maintenance and not a separate covered service.  DMEPOS suppliers must provide equipment-related services consistent with the manufacturer's specifications and in accordance with all federal, state, and local laws and regulations. Equipment-related services may include, but are not limited to, checking oxygen system purity levels and flow rates, changing and cleaning filters, and assuring the integrity of equipment alarms and back-up systems. However, more extensive maintenance, as recommended by the manufacturer and performed by authorized technicians, is considered repairs. This may include breaking down sealed components and performing tests that require specialized testing equipment not available to the member. The supplier of a capped rental item that supplied the item the 13th month must provide maintenance and service for the item. In very rare circumstances of malicious damage, culpable neglect, or wrongful disposition, the supplier may document the circumstances and be relieved of the obligation to provide maintenance and service.

(c) Replacement.

(1) If a capped rental item of equipment has been in continuous use by the member for the equipment's useful life or if the item is irreparably damaged, lost, or stolen, a prior authorization must be submitted to obtain new equipment. The reasonable useful lifetime for capped rental equipment cannot be less than five years. Useful life is determined by the delivery of the equipment to the member, not the age of the equipment.

(2) Replacement parts must be billed with the appropriate HCPCS code that represents the item or part being replaced along with a pricing modifier and replacement modifier. If a part that has not been assigned a HCPCS code is being replaced, the provider should use a miscellaneous HCPCS code to bill each part. Each claim that contains miscellaneous codes for replacement parts must include a narrative description of the item, the brand name, model name/number of the item, and an invoice.

(d) Delivery. DMEPOS products are set with usual maximum quantities and frequency limits. Suppliers are not expected to provide these amounts routinely, nor are members required to accept DMEPOS products at frequencies or in quantities that exceed the amount the member would typically use. Suppliers must not dispense a quantity of any DMEPOS product exceeding a member's expected utilization. The reordering or refilling of DMEPOS products should always be based on actual member usage.  Suppliers should stay attuned to atypical utilization patterns on behalf of their members and verify with the ordering physician that the atypical utilization is warranted. Suppliers must exercise the following guidelines in regard to the delivery of DMEPOS products:

(1) For DMEPOS products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill. This shall be done to ensure that the refilled item is necessary and to confirm any changes/modifications to the order. Contact with the member regarding refills should take place no sooner than 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier must deliver the DMEPOS product no sooner than 5 days prior to the end of the usage for the current product. This is regardless of which delivery method is utilized. A member must specifically request the refill before a supplier dispenses the product. Suppliers must not automatically dispense a quantity of supplies on a predetermined basis, even if the member has authorized this in advance. The supplier must have member contact documentation on file to substantiate that the DMEPOS product was refilled in accordance with this section.

(2) For DMEPOS products that are supplied via mail order, suppliers must bill using the appropriate modifier which indicates that the DMEPOS product was delivered via the mail. Reimbursement for DMEPOS products supplied and delivered via mail may be at a reduced rate.
(3) For DMEPOS products that are covered in the scope of the SoonerCare program, the cost of delivery is always included in the rate for the covered item(s).

317:30⊂chapter=5∂=17--211.6.General documentation requirements
[Issued 07-01-07]
Section 1833(e) of the Social Security Act precludes payment to any provider of service unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" [42 U.S.S. Section 13951(e)]. The member's medical records will reflect the need for the care provided. The member's medical records should include the physician's office records, hospital records, nursing home records, home health agency records, records from other health care professionals and test reports. This documentation must be provided for prior authorization requests and available to the OHCA or its designated agent upon request.

317:30⊂chapter=5∂=17--211.7.Free choice
[Revised 09-01-15]
   A member has the choice of which provider will fill the prescription or order for a DMEPOS. All providers must inform the member they have a choice of provider when filling or ordering DMEPOS.
317:30⊂chapter=5∂=17--211.8.Coverage [REVOKED]

[Revoked 12-03-09]
 

317:30⊂chapter=5∂=17--211.9.Adaptive equipment

[Revised 09-01-15]
(a) Residents of ICF/IID facilities. Payment is made for customized adaptive equipment for persons residing in private Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). This means customized equipment or devices to assist in ambulation. Standard wheelchairs, walkers, eyeglasses, etc., would not be considered customized adaptive equipment. All customized adaptive equipment must be prescribed by a physician and requires prior authorization.
(b) Members in home and community-based waivers. Refer to OAC 317:40-5-100.

317:30⊂chapter=5∂=17--211.10.Durable medical equipment (DME)

[Revised 09-01-15]
(a) DME. DME includes, but is not limited to: medical supplies, orthotics and prosthetics, custom braces, therapeutic lenses, respiratory equipment, and other qualifying items when acquired from a contracted DME provider.
(b) Certificate of medical necessity. Certain items of DME require a CMN/OHCA CMN which should be submitted with the request for prior authorization. These items include, but are not limited to:

(1) hospital beds;

(2) support surfaces;

(3) patient lift devices;

(4) external infusions pumps;

(5) enteral and parenteral nutrition;

(6) Oxygen and oxygen related products; and

(7) pneumatic compression devices.

(c) Prior authorization.

(1) Rental. Rental of hospital beds, support surfaces, oxygen and oxygen related products, continuous positive airway pressure devices (CPAP and BiPAP), pneumatic compression devices, and lifts require prior authorization and, except for CPAP and BiPAP devices, a completed CMN/OHCA CMN; medical necessity must be documented in the member's medical record, signed by the physician, and attached to the PA.

(2) Purchase. Equipment may be purchased when a member requires the equipment for an extended period of time.  During the prior authorization review, the OHCA may change the authorization from a rental to a purchase or a purchase to a rental based on the documentation submitted.  The provider must indicate whether the DME item provided is new or used.

(d) Backup equipment. Backup equipment is considered part of the rental cost and is not a covered service without prior authorization.
(e) Home modification. Equipment used for home modification is not a covered service.

317:30⊂chapter=5∂=17--211.11.Oxygen and oxygen equipment

[Revised 09-01-15]

(a) Medical necessity.  Oxygen and oxygen supplies are covered when medically necessary.  Medical necessity is determined from results of arterial blood gas analysis (ABG) or pulse oximetry (SaO2) tests. ABG data are not required for children, but may be used if otherwise available. The test results to document Medical Necessity must be within 30 days of the date of the qualified medical practitioner's Certificate of Medical Necessity. Prior authorization is required after the initial three months of billing whether qualifying tests were done at rest, during sleep, or during exercise. Appropriate documentation of ABG or SaO2 data from the member's chart should be attached to the prior authorization request(PAR).

(1) The ABG or oximetrytest used to determine medical necessity must be performed by a medical professional qualified to conduct such testing.  The test may not be performed or paid for by a DMEPOS supplier,or a related corporation. A referring qualified medical practitioner may perform the test in his/her office as part of routine member care.

(2) In addition to ABG data, the following three tests are acceptable for determining medical necessity for oxygen prescription:

(A) At rest and awake "spot oximetry."

(B) During sleep:

(i) Overnight Sleep Oximetry done inpatient or at home.

(ii) Polysomnogram, which may be used only if medically necessary for concurrent evaluation of another condition while in a chronic stable state.

(C) During exercise with all three of the following  performed in the same testing session.

(i) At rest, off oxygen showing a non-qualifying  result.

(ii) During exercise, off oxygen showing a qualifying event.

(iii) During exercise, on oxygen showing improvement over test (C) ii above.

(3) Certification criteria:

(A) All qualifying testing must meet the following criteria:
(B)  Adults .   Initial requests for oxygen must include ABG or resting oximetry results. At rest and on room air, the arterial blood saturation (SaO2) cannot exceed 89% or the pO2 cannot exceed 59mm Hg.

(C) Children .   Members 20 years of age or less must meet the following requirements:

(i) birth through three years, SaO2 equal to or less than 94%;or(ii) ages four and above, SaO2 level equal to or less than 90%.(iii)Requests from the qualified medical practitioner for oxygen for children who do not meet these requirements should include documentation of themedical necessity based on the child's clinical condition.  These requests are considered on a case-by-case basis.

(b) Certificate of medical necessity.

(1) The DMEPOS supplier must have a fully completed current CMN(CMS-484 or HCA-32 must be used for members 20 years of age and younger) on file to support the claims for oxygen or oxygen supplies, and to establish whether coverage criteria are met and to ensure that the oxygen services provided are consistent with the physician's prescription (refer to instructions from Palmetto Government Benefits Administration, the Oklahoma Medicare Carrier, for further requirements for completion of the CMN).

(2) The CMN must be signed by the qualified medical practitioner prior to submitting the initial claim.  If a verbal order containing qualifying data is received by the DME provider, oxygen and supplies may be dispensed using the verbal order date as the billing date.  The CMN initial date, the verbal order date, and the date of delivery should be the same date. It is acceptable to have a cover letter containing the same information as the CMN, stating the qualified medical practitioner's orders.  The CMN signed by the qualified medical practitioner must be attached to the PAR.

(3) The medical and prescription information on the CMN may be completed by a non-physician clinician, or an employee, for the qualified medical practitioner's review and signature.

(4) When a Certificate ofMedical Necessity for oxygen is recertified, a prior authorization requestwill berequired.

(5) Re-certification andrelatedretestingwill be required every 12 months.

(6)CMN for oxygen services must be updated at least annually and at any time a change in prescription occurs during the year.  All DMEPOS suppliers are responsible for maintaining the prescription(s) for oxygen services and CMN in each member's file. 
(7) The OHCA or its designated agent will conduct ongoing   monitoring of prescriptions for oxygen services to ensure guidelines are followed. Payment adjustments will be made on claims not meeting these requirements.

317:30⊂chapter=5∂=17--211.12.Oxygen rental

[Revised 09-01-15]

A monthly rental payment is made for rental of liquid oxygen systems, gaseous oxygen systems and oxygen concentrators. The rental payment for a stationary system includes all contents and supplies, such as, regulators, tubing, masks, etc., that are medically necessary.  An additional monthly payment may be made for a portable liquid or gaseous oxygen system based on medical necessity.

(1) Stationary oxygen systems and portable oxygen systems are covered items for members residing in their home or in a nursing facility.

(2) For members who meet medical necessity criteria, SoonerCare covers portable liquid or gaseous oxygen systems. Portable oxygen contents are not covered for adults. The need for a portable oxygen system must be stated on the CMN. A portable system that is used as a backup system only is not a covered item.
(3) When four or more liters of oxygen are medically necessary, an additional payment will be paid up to 150% of the allowable for a stationary system when billed with the appropriate modifier.

317:30⊂chapter=5∂=17--211.13.Prosthetic devices
[Revised 12-03-09]
Coverage of prosthetics for adults is limited to (1) home dialysis equipment and supplies, (2) nerve stimulators, (3) external breast prosthesis and support accessories, and (4) implantable devices inserted during the course of a surgical procedure. Prosthetics prescribed by an appropriate medical provider and as specified in this section are covered items for adults. There is no coverage of orthotics for adults.
(1) Home dialysis. Equipment and supplies are covered items for members receiving home dialysis treatments only.
(2) Nerve stimulators. Payment is made for transcutaneous nerve stimulators, implanted peripheral nerve stimulators, and neuromuscular stimulators.
(3) Breast prosthesis, bras, and prosthetic garments.
(A)Payment is limited to:
(i) one prosthetic garment with mastectomy form every 12 months for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;
(ii) two mastectomy bras per year; and
(iii) one silicone or equal breast prosthetic per side every 24 months; or
(iv) one foam prosthetic per side every six months.
(B) Payment will not be made for both a silicone and a foam prosthetic in the same 12 month period.
(C) Breast prostheses, bras, and prosthetic garments must be purchased from a Board Certified Mastectomy Fitter.
(D) A breast prosthesis can be replaced if:
(i) lost;
(ii) irreparably damaged (other than ordinary wear and tear); or
(iii) the member's medical condition necessitates a different type of item and the physician provides a new prescription explaining the need for a different type of prosthesis.
(E) External breast prostheses are not covered after breast reconstruction is performed except in instances where a woman with breast cancer receives reconstructive surgery following a mastectomy, but the breast implant fails or ruptures and circumstances are such that an implant replacement is not recommended by the surgeon and/or desired by the member.
(4) Prosthetic devices inserted during surgery. Separate payment is made for prosthetic devices inserted during the course of surgery when the prosthetic devices are not integral to the procedure and are not included in the reimbursement for the procedure itself.
317:30⊂chapter=5∂=17--211.14.Nutritional support
[Revised 12-03-09]
(a) Parenteral nutrition. The member must require intravenous feedings to maintain weight and strength commensurate with the member's overall health status. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.
(1) The member must have a permanent impairment. Permanence does not require a determination that there is no possibility that the member's condition may improve sometime in the future. If the judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least three months), the test of permanence is met. Parenteral nutrition will be denied as a non-covered service in situations involving temporary impairments.
(2) The member must have a condition involving the small intestine, exocrine glands, or other conditions that significantly impair the absorption of nutrients. Coverage is also provided for a disease of the stomach and/or intestine that is a motility disorder and impairs the ability of nutrients to be transported through the GI system, and other conditions as deemed medically necessary. There must be objective medical evidence supporting the clinical diagnosis.
(3) Re-certification of parenteral nutrition will be required as medically necessary and determined by the OHCA medical staff.
(b) Prior authorization. A written signed and dated order must be received by the supplier before a claim is submitted to the OHCA. If the supplier bills an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary. The ordering physician is expected to see the member within 30 days prior to the initial certification or required re-certification. If the physician does not see the member within this time frame, the physician must document the reason why and describe what other monitoring methods were used to evaluate the member's parenteral nutrition needs.
(c) Enteral formulas. Enteral formulas are covered for children only. See OAC 317:30-5-210.2.

 

317:30⊂chapter=5∂=17--211.15.Supplies
[Revised 09-01-16]

The OHCA provides coverage for medically necessary supplies that are prescribed by the appropriate medical provider and meet the special requirements below:

(1) Intravenous therapy. Supplies for intravenous therapy are covered items. Drugs for IV therapy are covered items only as specified by the Vendor Drug program.

(2) Diabetic supplies. Glucose test strips and lancets are covered when medically necessary and prescribed by a physician, physician assistant, or an advanced practice nurse. Testing supplies may be limited based on insulin use or type of diabetes. Prior authorization may be required for supplies beyond the standard allowance.

(3) Catheters. Permanent indwelling catheters, male external catheters, drain bags and irrigation trays are covered items. Single use self catheters when the member has a history of urinary tract infections is a covered item. The prescription from the attending physician must indicate such documentation is available in the member's medical record.

(4) Colostomy and urostomy supplies. Colostomy and urostomy bags and accessories are covered items.

317:30⊂chapter=5∂=17--211.16.Coverage for nursing facility residents
[Issued 07-01-07]
(a) For residents in a nursing facility, most DMEPOS are considered part of the facility's per diem rate. The following are not included in the per diem rate and may be billed by the appropriate medical supplier:
(1) Services requiring prior authorization:
(A) ventilators and supplies;
(B) total parenteral nutrition (TPN), and supplies;
(C) custom seating for wheelchairs; and
(D) external breast prosthesis and support accessories.
(2) Services not requiring prior authorization:
(A) permanent indwelling or male external catheters and catheter accessories;
(B) colostomy and urostomy supplies;
(C) tracheostomy supplies;
(D) catheters and catheter accessories;
(E) oxygen and oxygen concentrators.
(i) PRN oxygen. Members in nursing facilities requiring oxygen PRN will be serviced by oxygen kept on hand as part of the per diem rate.
(ii) Billing for Medicare eligible nursing home members. Oxygen supplied to Medicare eligible nursing home members may be billed directly to OHCA. It is not necessary to obtain a denial from Medicare prior to filing the claim with OHCA.
(b) Items not covered include but are not limited to:
(1) diapers;
(2) underpads;
(3) medicine cups;
(4) eating utensils; and
(5) personal comfort items.

317:30⊂chapter=5∂=17--211.17.Wheelchairs
[Revised 09-01-15]

(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.

(1) "Assistive technology professional" or "ATP" means a for-service provider who is involved in analysis of the needs and training of a consumer in the use of a particular assistive technology device or is involved in the sale and service of rehabilitation equipment or commercially available assistive technology products and devices.

(2) "Custom seating system" means a wheelchair seating system which is individually made for a member using a plaster model of the member, a computer generated model of the member (e.g., CAD-CAM technology), or the detailed measurements of the member to create either:

(A) a molded, contoured, or carved (foam or other suitable material) custom-fabricated seating system that is incorporated into the wheelchair base; or

(B) a custom seating system made from multiple pre-fabricated components or a combination of custom fabricated materials and pre-fabricated components which have been configured and attached to the wheelchair base or incorporated into a wheelchair seat and/or back in a manner that the wheelchair could not be easily re-adapted for use by another individual.

(3) "RESNA" means the Rehabilitation Engineering and Assistive Technology Society of North America.

(4) "Specialty evaluation" means the determination and documentation of the consumer's pathology, history and prognosis, and the physiological, functional, and environmental factors that impact the selection of an appropriate wheeled mobility system.

(b) Medical Necessity. Medical necessity, pursuant to OAC 317:30-5-211.2, is required for a wheelchair to be covered and reimbursed by SoonerCare. Only one wheelchair is covered as medically necessary during its reasonable useful lifetime, unless the member's documented medical condition indicates the current wheelchair no longer meets the member's medical need. Backup wheelchairs are not covered items.

(c) Prior authorization. Prior authorization, pursuant to OAC 317:30-5-211.3, is required for selected wheelchairs to be covered and reimbursed by SoonerCare. All prior authorization requests for the purchase of a wheelchair must indicate the length of the warranty period and what is covered under the warranty.

(1) Wheelchairs, wheelchair parts and accessories, and wheelchair modifications that are beneficial primarily in allowing the member to perform leisure or recreational activities are not considered medically necessary and will not be authorized.

(2) Wheelchair parts, accessories, and/or modifications that are distinctly and separately requested and priced from the original wheelchair request may require prior authorization.

(3) The OHCA will deny prior authorization requests when the required forms have not been fully completed or the member's medical record does not provide sufficient information to establish medical necessity or to determine that the criteria for coverage has been met.

(d) Coverage and limitations.

(1) For a member who resides in a personal residence, assisted living facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or long term care facility, the following criteria must be met for the authorization to purchase a wheelchair.

(A) The member must have a prescription signed by a physician, a physician assistant, or an advanced registered nurse practitioner.

(B) The member must meet the requirements for medical necessity as determined and approved by the OHCA.

(C) The member must either have:

(i) a specialty evaluation that was performed by a licensed or certified medical professional, such as a physical therapist, occupational therapist, or a physician who has specific training and experience in rehabilitation wheelchair evaluations, and that documents the medical necessity for the wheelchair and its special features; or

(ii) a wheelchair provided by a supplier that employs a RESNA certified assistive technology professional who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

(2) For members who reside in a long term care facility or ICF/IID, only custom seating systems for wheelchairs are eligible for direct reimbursement to DME providers. All standard manual and power wheelchairs are the responsibility of the facility and are considered part of the facility's per diem rate. Repairs and maintenance, except for custom seating systems, are not covered items for wheelchairs and are considered part of the facility's per diem rate.

(e) Rental, repairs, maintenance, and delivery.  Refer to OAC 317:30-5-211.4 through 317:30-5-211.5.

(f) Documentation.

(1) The specialty evaluation or wheelchair selection documentation must be submitted with the prior authorization request.

(2) The specialty evaluation or wheelchair selection must be performed no longer than 90 days prior to the submission of the prior authorization request.

(3) The results of the specialty evaluation or wheelchair selection documentation must be supported by the information submitted on the member's medical record.

(4) A copy of the dated and signed written specialty evaluation or wheelchair selection document must be maintained by the wheelchair provider. The results of the specialty evaluation or wheelchair selection must be written, signed, and dated by the medical professional who evaluated the member or the ATP who was involved in the wheelchair selection for the member.
317:30⊂chapter=5∂=17--211.18.Ownership of durable medical equipment
[Issued 12-03-09]
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) purchased by SoonerCare are the property of the Oklahoma Health Care Authority (OHCA) to be used for the benefit of the requesting member until it is no longer medically necessary. At such time as the item is no longer medically necessary, OHCA or an OHCA contractor may retrieve the DMEPOS product if it is determined to be administratively and fiscally prudent.

 

317:30⊂chapter=5∂=17--211.19.Quality assurances and safeguards
[Issued 06-25-11]
All SoonerCare billed durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) must have the following quality assurances and safeguards:
(1) All DMEPOS items provided to SoonerCare members must meet manufacturer standards. The equipment must be provided by trained professionals in a manner that is both nationally recognized for safe and effective member care and that meets the member's needs and therapeutic goals, and that the member has received the appropriate education in order to minimize any hazard or safety risks.
(A) DMEPOS suppliers must only provide items that meet applicable state and federal regulations and medical device effectiveness and safety standards.
(B) DMEPOS suppliers must make available the manufacturer copies of the features, warranties, and instructions for each type of item.
(2) All DMEPOS supplier personnel who are educating SoonerCare members, or repairing SoonerCare DMEPOS items, must be working within the scope of their practice and meet all state and federal requirements.
(A) DMEPOS suppliers must have equipment delivery, set-up, and member education accomplished by competent technical and professional personnel who are licensed, certified, or registered, and who are functioning within their scope of practice as required by state and federal standards.
(B) DMEPOS suppliers must provide the appropriate information about equipment set-up features, routine use, troubleshooting, cleaning, and maintenance.
(C) DMEPOS suppliers must provide education and instructional material that is tailored to the member's needs, abilities, learning preferences, and language.
(D) DMEPOS suppliers must make repairs and maintenance available on all equipment and item(s) provided.
(3) DMEPOS suppliers must implement a program that promotes the safe use of equipment, and minimizes safety risks, infections, and hazards. Suppliers must investigate any incident, injury, or infection in which DMEPOS items were a contributor.
(A) DMEPOS suppliers must provide relevant information about infection control issues related to the use of the equipment and item(s) provided.
(B) DMEPOS suppliers must ensure that the member can use all equipment and item(s) provided safely and effectively in the settings of anticipated use.
(4) DMEPOS suppliers must make available their regular business hours and after-hour access telephone numbers for customer service, and for information about equipment repair, and emergency coverage.
(5) DMEPOS suppliers must provide follow-up services to members, consistent with the types of equipment and item(s) provided, and recommendations from the prescribing physician.
317:30⊂chapter=5∂=17--212.Coverage for children [REVOKED]
[Revoked 12-03-09]
317:30⊂chapter=5∂=17--213.Coverage for vocational rehabilitation [REVOKED]
[Revoked 8-05-98]

317:30⊂chapter=5∂=17--214.Coverage for individuals eligible for Part B of Medicare
[Revised 7-1-02]
Payment is made to medical suppliers utilizing the Medicaid allowable for comparable services.

317:30⊂chapter=5∂=17--215.Billing requirements
[Revoked 07-01-07]

317:30⊂chapter=5∂=17--216.Prior authorization requests
[Revised 09-12-14]

(a) Prior authorization requirements. Requirements vary for different types of services. Providers should refer to the service-specific sections of policy or the OHCA website for services requiring PA.

(1) Required forms. All required forms are available on the OHCA web site at www.okhca.org.

(2) Certificate of medical necessity. The prescribing provider must complete the medical necessity section of the CMN.  This section cannot be completed by the supplier. The medical necessity section can be completed by any health care clinician; however, only the member's treating provider may sign the CMN. By signing the CMN, the physician is validating the completeness and accuracy of the medical necessity section. The member's medical records must contain documentation substantiating that the member's condition meets the coverage criteria and the answers given in the medical necessity section of the CMN. These records may be requested by OHCA or its representatives to confirm concurrence between the medical records and the information submitted with the prior authorization request.

(b) Submitting prior authorization requests. Contact information for submitting prior authorization requests may be found in the OHCA Provider Billing and Procedures Manual. An electronic version of this manual is located on the OHCA web site.

(c) Prior authorization review. Upon verifying the completeness and accuracy of clerical items, the PA request is reviewed by OHCA staff to evaluate whether or not each service being requested meets SoonerCare's definition of "medical necessity" [see OAC 317:30-3-1 (f)] as well as other criteria.

(d) Prior authorization decisions. After the PA request is processed, a notice will be issued regarding the outcome of the review. If the request is approved the notice will include an authorization number, the appropriate date span and procedure codes approved.

(e) Prior authorization does not guarantee reimbursement. Provider status, member eligibility, and medical status on the

date of service, as well as all other SoonerCare requirements, must be met before the claim is reimbursed.

(f) Prior authorization of manually-priced items. Manually-priced items must be prior authorized. If manual pricing is used, the provider is reimbursed at the provider's documented Manufacturer's Suggested Retail Price (MSRP) minus 30% or invoice cost plus 30%, whichever is the lesser of two. OHCA may establish a fair market price through claims review and analysis.
317:30⊂chapter=5∂=17--217.Billing

[Revised 09-01-15]

(a) Procedure codes. It is the supplier's responsibility to ensure that claims for the supply or equipment are submitted with the most appropriate HCPCS code as assigned by the Medicare PDAC or its successor. When the most appropriate procedure code is not used, the claim will be denied. When a specific procedure code has not been assigned to an item, an invoice is required which must contain a full description of the equipment or supply.

(b) Rental. Claims for rental should indicate the first date of service and the inclusive dates of rental as part of the description of services. The appropriate modifier must be included. Only one month's rental should be entered on each detail line.

(c) Invoice. For manually priced items, after the service has been provided, the supplier is required to include a copy of the invoice documenting the supplier's cost of the item with the claim.

(d) Place of service. The appropriate indicator for the patient's place of residence must be entered.

(e) Prescribing provider. The name of the prescribing provider must be included for claims processing and entered in the appropriate block.
(f) Proof of Delivery. Items must be received by the member before billing OHCA. Proof of delivery must be retained by the provider in the member's file and provided to the OHCA upon request. In addition, for manually priced items, evidence of proof of delivery must be attached to the claim for adjudication.

317:30⊂chapter=5∂=17--218.Reimbursement

[Revised 09-01-15]

(a) Medical equipment and supplies. Reimbursement for durable medical equipment and supplies will be made using an amount derived from the lesser of the OHCA maximum allowable fee or the provider's usual and customary charge. The maximum allowable fee is the maximum amount that the OHCA will pay a provider for an allowable procedure. When a code is not assigned a maximum allowable fee for a unit of service, a fee will be established.  The fee schedule will be reviewed annually and adjustments to the fee schedule may be made at any time based on efficiency, budget considerations, and quality of care as determined by the OHCA.

(b) Oxygen equipment and supplies.

(1) Payment for stationary oxygen systems (liquid oxygen systems, gaseous oxygen systems, and oxygen concentrators) is based on continuous rental, i.e., a continuous monthly payment that is made as long as it is medically necessary. The rental payment includes all contents and supplies, e.g. regulators, tubing, masks, etc. Portable oxygen systems are considered continuous rental. Ownership of the equipment remains with the supplier.

(2) Separate payment will not be made for maintenance, servicing, delivery, or for the supplier to pickup the equipment when it is no longer medically necessary.
(3) Payment for oxygen and oxygen equipment and supplies will not exceed the Medicare fee for the same procedure code.  Reimbursement for members who reside in a nursing facility may be at a reduced rate. The fee schedule will be reviewed annually and adjustments to the fee schedule may be made at any time based on efficiency, budget considerations, and quality of care as determined by the OHCA.


 

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.