OHCA Policies and Rules

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Part       GENETIC COUNSELORS

317:30⊂chapter=5∂=18--219.General Information
[Issued 11-01-07]
Genetic counseling gathers critical family history, patient history, and other factors to be analyzed and shared with the member to help them understand and adapt to the medical, psychosocial and familial contributions to potential or realized birth defects.

317:30⊂chapter=5∂=18--220.Eligible Providers
[Issued 11-01-07]
Eligible providers must be Licensed Genetic Counselors. Genetic Counselors must have a current contract on file with the Oklahoma Health Care Authority and be licensed in the state in which the service is being provided.

317:30⊂chapter=5∂=18--221.Coverage

[Revised 07-01-13]
a) Genetic counseling services are covered for SoonerCare members who meet the criteria for receiving medically necessary genetic testing as set forth in 317:30-5-2(a)(1)(GG) and for pregnant/postpartum SoonerCare members as set forth in this section. Services for pregnant/postpartum SoonerCare members must be referred by a provider involved in the provision of obstetric or pediatric care.  Members are eligible for genetic counseling during pregnancy which includes 60 days postpartum.  Reasons for genetic counseling include but are not limited to the following:

(1) advanced maternal age;

(2) abnormal maternal serum first or second screening;

(3) previous child or current fetus/infant with an   abnormality;

(4) consanguinity/incest;

(5) parent is a known carrier or has a family history of a genetic condition;

(6) parent was exposed to a known or suspected reproductive hazard;

(7) previous fetal demise, stillbirth, or neonatal death involving known/suspected abnormalities;

(8) history of recurrent pregnancy loss; or

(9) parent(s) are in an ethnic or racial group associated with an increased risk for specific genetic conditions.

(b) These services may be provided in an office or outpatient setting.

317:30⊂chapter=5∂=18--222.Reimbursement
[Issued 11-01-07]
(a) Counseling services must be billed using appropriate CPT codes and guidelines and must be medically necessary. SoonerCare does not allow more than six units (30 minutes = 1 unit) per pregnancy including 60 days postpartum care.
(b) Genetic Counselors who are employed by or remunerated by another provider may not bill the SoonerCare program directly for services if that billing would result in duplicate payment for the same service.

317:30⊂chapter=5∂=18--223.Documentation

[Revised 07-01-13]

All services must be documented in the member's medical record. All genetic counseling sessions must, at a minimum, include the following:

(1) date of service;

(2) start and stop time for each treatment session;

(3) practitioner's signature;

(4) pedigree, and/or review and interpretation of family history; and

(5) recommendation and plan of care.

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.