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Part 103      QUALIFIED SCHOOLS AS PROVIDERS OF HEALTH RELATED SERVICES

317:30-5-1020.General provisions
[Revised 09-14-18]

(a) School-based services are medically necessary health-related and rehabilitative services that are provided by a qualified school provider to a student under the age of 21 pursuant to an Individualized Education Program (IEP), in accordance with the Individuals with Disabilities Education Act (IDEA). Payment is made to qualified school providers for delivery of school-based services, provided that such services are, among other things, medically necessary and sufficiently supported by medical records and/or other documentation, as explained below.

(b) An IEP and all relevant supporting documentation, including, but not limited to, the documentation required by OAC 317:30-5-1020(c), below, serves as the plan of care for consideration of reimbursement for school-based services. The plan of care must contain, among other things, the signatures, including credentials, of the provider(s) and the direct care staff delivering services under the supervision of the professional; as well as a complete, signed, and current IEP which clearly establishes the type, frequency, and duration of the service(s) to be provided, the specific place of services if other than the school (e.g., field trip, home), and measurable goals for each of the identified needs. Goals must be updated to reflect the current therapy, evaluation, or service that is being provided and billed to SoonerCare.

(1) Except for those services, referenced in Oklahoma Administrative Code (OAC) 317:30-5-1023(b)(4)(H), a plan of care that meets the requirements of OAC 317:30-5-1020(b), above, shall serve as a prior medical authorization for the purpose of providing medically necessary and appropriate school-based services to students.

(2) For the purposes of occupational therapy services, and services for members with speech, hearing, and language disorders, a plan of care that meets the requirements of OAC 317:30-5-1020(b), above, may also, in accordance with sections ( '' ) 725.2(H) and 888.4(C) of Title 59 of the Oklahoma Statutes (O.S.) serve as a valid prescription or referral for an initial evaluation and any subsequent services, as is required by Title 42 of Code of Federal Regulations (C.F.R.), ' 440.110.

(3) Physical therapy services, by contrast, shall require a signed and dated prescription from the student's physician prior to that student's initial evaluation, in accordance with OAC 317:30-5-291(1). Prescriptions for school-based physical therapy must be reauthorized at least annually, and documented within Oklahoma State Department of Education's (OSDE) online IEP system, as set forth in subsection (c), below.

(c) Qualified school providers must ensure that adequate documentation is maintained within the OSDE online IEP system in order to substantiate that all school-based services billed to SoonerCare are medically necessary and comply with applicable state and federal Medicaid law. Such documentation shall include, among other things:

(1) Documentation establishing sufficient notification to a member's parents and receipt of adequate, written consent from them, prior to accessing a member's or parent's public benefits or insurance for the first time, and annually thereafter, in accordance with 34 C.F.R. ' 300.154;

(2) Any referral or prescription that is required by state or federal law for the provision of school-based services, or for the payment thereof, in whole or in part, from public funds, including, but not limited to, 42 C.F.R. ' 440.110. However, any prescription or referral ordered by a physician or other licensed practitioner of the healing arts who has, or whose immediate family member has, a financial interest in the delivery of the underlying service in violation of Section 1395nn, Title 42 of United States Code shall not be valid, and services provided thereto shall not be eligible for reimbursement by the Oklahoma Health Care Authority (OHCA);

(3) An annual evaluation located in or attached to the IEP that clearly demonstrates, by means of the member's diagnosis and any other relevant supporting information, that school-based services are medically necessary, in accordance with OAC 317:30-3-1(f). Evaluations completed solely for educational purposes are not compensable. Evaluations must be completed annually and updated to accurately reflect the student's current status. Any evaluation for medically necessary school-based services, including but not limited to, hearing and speech services, physical therapy, occupational therapy, and psychological therapy, must include the following information:

(A) Documentation that supports why the member was referred for evaluation;

(B) A diagnosis that clearly establishes and supports the need for school-based services;

(C) A summary of the member's strengths, needs, and interests;

(D) The recommended interventions for identified needs, including outcomes and goals;

(E) The recommended units and frequency of services; and

(F) A dated signature and the credentials of the professional completing the evaluation; and

(4) Documentation that establishes the medical necessity of the school-based services being provided between annual evaluations, including, for example, professional notes or updates, reports, and/or assessments that are signed, dated, and credentialed by the rendering practitioner.

(d) All claims related to school-based services that are submitted to OHCA for reimbursement must include any numeric identifier obtained from OSDE.

 
317:30-5-1021.Eligible providers
[Revised 09-14-18]

(a) Eligible providers are local, regional, and state educational services agencies as defined by state law and the Individuals with Disabilities Education Act (IDEA), as most recently amended (hereinafter, "school providers").  School providers must submit a completed contract to the Oklahoma Health Care Authority (OHCA), including a Special Provisions for Schools, and must receive approval thereof prior to receiving reimbursement for school-based services.

(b) Qualified school providers must notify OHCA of all subcontractors performing Individualized Education Program (IEP) related evaluations and services in the school setting prior to services being rendered. The notification must include a copy of the agreement between the school and subcontractor and must reflect the start and ending dates of the agreement for services. All subcontractors must be individually contracted with SoonerCare and, if rendering services, must be identified on any claim for payment as the rendering provider.

317:30-5-1022.Periodicity schedule

[Revised 10-01-18]
(a) The SoonerCare program has adopted the recommendations of the American Academy of Pediatrics' Bright Futures' periodicity schedule for services.

(b) Children and adolescents enrolled in SoonerCare are referred to their SoonerCare provider for services. In cases where the SoonerCare provider authorizes the school to perform the screen or fails to schedule an appointment within three (3) weeks and a request has been made and documented by the school, the school may then furnish the Early and Periodic Screening, Diagnosis and Treatment child-health screening and bill it as a fee-for-service activity. Results of the child-health screening are forwarded to the member's SoonerCare provider.

317:30-5-1023.Coverage by category
[Revised 09-14-18] 

(a) Adults.  There is no coverage for services rendered to adults.

(b) Children.  Payment is made for the following compensable services rendered by qualified school providers:

(1) Child-health screening.  An initial screening may be requested by an eligible member at any time and must be provided without regard to whether the member's age coincides with the established periodicity schedule. Coordination referral is made to the SoonerCare provider to assure at a minimum, that periodic screens are scheduled and provided in accordance with the periodicity schedule following the initial screening. Child-health screening must adhere to the following requirements:

(A) Children and adolescents enrolled in SoonerCare must be referred to their SoonerCare provider for child-health screenings. In cases where the SoonerCare provider authorizes the school to perform this screen or fails to schedule an appointment within three (3) weeks and a request has been made and documented by the school, the school may then furnish the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) child-health screening. Written notification must be mailed to the SoonerCare member's primary care provider (PCP) prior to the school's intent to furnish and bill for the screen. Results of this screening must be forwarded to the member's SoonerCare provider.

(B) Child-health screenings must be provided by a state-licensed physician (M.D. or D.O.), state-licensed nurse practitioner with prescriptive authority, or state-licensed physician assistant. Screening services must include the following:

(i) Comprehensive health and developmental history, including assessment of both physical and mental health development;

(ii) Comprehensive unclothed physical exam;

(iii) Appropriate immunizations according to the age and health history;

(iv) Laboratory test, including blood level assessment; and

(v) Health education, including anticipatory guidance.

(C) Mass screenings for any school-based service are not billable to SoonerCare, nor are screenings that are performed as a child or adolescent find activity pursuant to an Individuals with Disabilities Education Act (IDEA) requirement. There must be a documented referral in place that indicates the child or adolescent has an individualized need that warrants a screening to be performed.

(2) Child-health encounter.  The child-health encounter may include a diagnosis and treatment encounter, a follow-up health encounter, or a home visit.  A child-health encounter may include any of the following services:

(A) vision;

(B) hearing;

(C) dental;

(D) a health history;

(E) physical examination;

(F) developmental assessment;

(G) nutrition assessment and counseling;

(H) social assessment and counseling;

(I) genetic evaluation and counseling;

(J) indicated laboratory and screening tests;

(K) screening for appropriate immunizations; or

(L) health counseling and treatment of childhood illness and conditions.

(3) Diagnostic encounters. Diagnostic encounters are defined as those services necessary to fully evaluate defects, physical or behavioral health illnesses or conditions discovered by the screening. Approved diagnostic encounters may include the following:

(A) Hearing and hearing aid evaluation.  Hearing evaluation includes pure tone air, bone and speech audiometry. Hearing evaluations must be provided by a state- licensed audiologist who:

(i) holds a Certificate of Clinical Competence from the American Speech-Language-Hearing Association (ASHA); or

(ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(B) Audiometry test.  Audiometric test (Immittance [Impedance] audiometry or tympanometry) includes bilateral assessment of middle ear status and reflex studies (when appropriate) provided by a state-licensed audiologist who:

(i) holds a Certificate of Clinical Competence from ASHA; or

(ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(C) Ear impression (for earmold).  Ear impression (for earmold) includes taking impression of a member's ear and providing a finished earmold which is used with the member's hearing aid provided by a state-licensed audiologist who:

(i)  holds a Certificate of Clinical Competence from the ASHA; or

(ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(D) Vision screening.  Vision screening in schools includes application of tests and examinations to identify visual defects or vision disorders. The vision screening may be performed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) under the supervision of an RN, or state-certified vision impairment teacher. The service can be billed when a SoonerCare member has an individualized documented concern that warrants a screening. A vision examination must be provided by a state-licensed Doctor of Optometry (O.D.) or licensed physician specializing in ophthalmology (M.D. or D.O.). This vision examination, at a minimum, includes diagnosis and treatment for defects in vision.

(E) Speech-language evaluation.  Speech-language evaluation is for the purpose of identification of children or adolescents with speech or language disorders and the diagnosis and appraisal of specific speech and language services. Speech-language evaluations must be provided by state-licensed speech-language pathologist who:

(i) holds a Certificate of Clinical Competence from the ASHA; or

(ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(F) Physical therapy evaluation. Physical therapy evaluation includes evaluating the student's ability to move throughout the school and to participate in classroom activities and the identification of movement dysfunction and related functional problems and must be provided by a state-licensed physical therapist. Physical therapy evaluations must adhere to guidelines found at OAC 317:30-5-291.

(G) Occupational therapy evaluation.  Occupational therapy evaluation services include determining what therapeutic services, assistive technology, and environmental modifications a student requires for participation in the special education program and must be provided by a state-licensed occupational therapist.

(H)  Psychological evaluation and testing.  Psychological evaluation and testing are for the purpose of diagnosing and determining if emotional, behavioral, neurological, or developmental issues are affecting academic performance and for determining recommended treatment protocol.  Evaluation/testing for the sole purpose of academic placement (e.g. diagnosis of learning disorders) is not a compensable service. Psychological evaluation and testing must be provided by state-licensed, board-certified psychologist or school psychologist certified by Oklahoma State Department of Education (OSDE).

(4) Child-guidance treatment encounter.  A child-guidance treatment encounter may occur through the provision of individual, family, or group treatment services to children and adolescents who are identified as having specific disorders or delays in development, emotional, or behavioral problems, or disorders of speech, language or hearing.  These types of encounters are initiated following the completion of a diagnostic encounter and subsequent development of a treatment plan, or as a result of an Individualized Education Program (IEP) and may include the following:

(A) Hearing and vision services. Hearing and vision services may include provision of habilitation activities, such as auditory training, aural and visual habilitation training, including Braille, and communication management, orientation and mobility, counseling for vision and hearing losses and disorders. Services must be provided by or under the direct guidance of one of the following individuals practicing within the scope of his or her practice under state law:

(i) state-licensed, Master's Degree Audiologist who:

(I) holds a Certificate of Clinical Competence from the ASHA; or

(II) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(III) has completed the academic program and is acquiring supervised work experience to qualify for the certificate;

(ii)state-licensed, Master's Degree Speech-Language Pathologist who:

(I) holds a Certificate of Clinical Competence from the ASHA; or

(II) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(III) has completed the academic program and is acquiring supervised work experience to qualify for the certificate;

(iii) state-certified deaf education teacher;

(iv)certified orientation and mobility specialists; and

(v) state-certified vision impairment teachers.

(B) Speech-language therapy services. Speech-language therapy services include provisions of speech and language services for the habilitation or prevention of communicative disorders. Speech-language therapy services must be provided by or under the direct guidance and supervision of a state-licensed Speech-Language Pathologist within the scope of his or her practice under state law who:

(i) holds a Certificate of Clinical Competence from the ASHA; or

(ii) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(iii) has completed the academic program and is acquiring supervised work experience to qualify for the certificate; or

(C) Physical therapy services.  Physical therapy services are provided for the purpose of preventing or alleviating movement dysfunction and related functional problems that adversely affects the member's education. Physical therapy services must adhere to guidelines found at OAC 317:30-5-291 and must be provided by or under the direct guidance and supervision of a state-licensed physical therapist; services may also be provided by a Physical Therapy Assistant who has been authorized by the Board of Examiners working under the supervision of a licensed Physical Therapist. The licensed Physical Therapist may not supervise more than three Physical Therapy Assistants.

(D) Occupational therapy services.  Occupational therapy may include provision of services to improve, develop or restore impaired ability to function independently. Occupational therapy services must be provided by or under the direct guidance and supervision of a state-licensed Occupational Therapist; services may also be provided by an Occupational Therapy Assistant who has been authorized by the Board of Examiners, working under the supervision of a licensed Occupational Therapist.

(E) Nursing services.  Nursing services may include provision of services to protect the health status of children and adolescents, correct health problems and assist in removing or modifying health related barriers and must be provided by a RN or LPN under supervision of a RN.  Services include medically necessary procedures rendered at the school site, such as catheterization, suctioning, tube feeding, and administration and monitoring of medication.

(F) Psychotherapy services. Psychotherapy services are the provision of counseling for children and parents.  All services must be for the direct benefit of the member.  Psychotherapy services must be provided by a state-licensed Social Worker, a state-licensed Professional Counselor, a state-licensed Psychologist or School Psychologist certified by the OSDE, a state-licensed Marriage and Family Therapist or a state-licensed Behavioral Practitioner, or under Board supervision to be licensed in one of the above stated areas.

(G) Assistive technology.  Assistive technology are the provision of services that help to select a device and assist a student with disability(ies) to use an assistive technology device including coordination with other therapies and training of member and caregiver.  Services must be provided by a:

(i) state-licensed, Speech-Language Pathologist who:

(I) holds a Certificate of Clinical Competence from the ASHA; or

(II) has completed the equivalent educational requirements and work experience necessary for the certificate; or

(III) has completed the academic program and is acquiring supervised work experience to qualify for the certificate;

(ii) state-licensed Physical Therapist; or

(iii) state-licensed Occupational Therapist.

(H) Personal care.  Provision of personal care services allow students with disabilities to safely attend school; includes, but is not limited to assistance with toileting, oral feeding, positioning, hygiene, and riding school bus to handle medical or physical emergencies.  Services must be provided by registered paraprofessionals/assistants that have completed training approved or provided by OSDE, or Personal Care Assistants, including LPNs, who have completed on-the-job training specific to their duties. Personal Care services do not include behavioral monitoring. Paraprofessionals are not allowed to administer medication, nor are they allowed to assist with or provide therapy services to SoonerCare members. Tube feeding of any type may only be reimbursed if provided by a RN or LPN. Catheter insertion and Catheter/Ostomy care may only be reimbursed when done by a RN or LPN.

(I)  Therapeutic behavioral services. Therapeutic behavioral services are interventions to modify the non-adaptive behavior necessary to improve the student's ability to function in the community as identified on the plan of care. Medical necessity must be identified and documented through assessment and annual evaluations/re-evaluations. Services encompass behavioral management, redirection, and assistance in acquiring, retaining, improving, and generalizing socialization, communication and adaptive skills. This service must be provided by a Behavioral Health School Aide (BHSA) who has a high school diploma or equivalent and has successfully completed the paraprofessional training approved by the OSDE and a training curriculum in behavioral interventions for pervasive developmental disorders as recognized by OHCA. BHSA must be supervised by a bachelor's level individual with a special education certification. BHSA must have CPR and First Aid certification. Six (6) additional hours of related continuing education are required per year.

(J) Immunization.  Immunizations must be coordinated with the PCP for children and adolescents enrolled inSoonerCare.  An administration fee, only, can be paid for immunizations provided by the schools.

(c) Members eligible for Part B of Medicare.  EPSDT school health-related services provided to Medicare eligible members are billed directly to the fiscal agent.

 
317:30-5-1024.Periodic screening examination
[Issued 8-01-97]
At a minimum, referrals to SoonerCare providers for periodic screening must be completed and provided in accordance with the periodicity schedule following the initial screening.

317:30-5-1025.Interperiodic screening examination

[Issued 09-12-14]
   Interperiodic screenings must be provided when medically necessary to determine the existence of suspected physical or mental illnesses or conditions.  They may include physical, mental or dental conditions.  The determination of whether an interperiodic screen is medically necessary may be made by a health, developmental or educational professional who comes into contact with the child outside of the formal health care system.  Children enrolled in SoonerCareare referred to their SoonerCare provider for these services.  In cases where the SoonerCare provider authorizes the School to perform the screen or fails to schedule an appointment within three weeks and a request has been made and documented by the School, the School may then furnish the EPSDT child health  screening  and bill it as a fee-for-services activity.  Results of this interperiodic screening are forwarded to the child's SoonerCare provider.

317:30-5-1026.Reporting of suspected child abuse/neglect

[Revised 06-25-09]
Instances of child abuse and/or neglect discovered through screenings and regular examinations are to be reported in accordance with State law. Section 7103 of Title 10 of the Oklahoma Statutes mandates reporting suspected abuse or neglect to the Oklahoma Department of Human Services. Section 7104 of Title 10 of the Oklahoma Statutes further requires reporting of criminally injurious conduct to the nearest law enforcement agency. 

317:30-5-1027.Billing
[Revised 09-01-17] 

(a) Each service has a specified unit of service (unit) for billing purposes which represents the actual time spent providing a direct service. Direct service must be face-to face with the child. There is no reimbursement for time reviewing/completing paperwork and/or documentation related to the service or for staff travel to/from the site of service, unless otherwise specified.

(1) Most units of service are time-based, meaning that the service must be of a minimum duration in order to be billed. A unit of service that is time-based is continuous minutes; the time cannot be aggregated throughout the day.

(2) There are no minimum time requirements for evaluation services, for which the unit of service is generally a completed evaluation. The only exception is the Psychological Evaluation, which is billed in hourly increments.

(b) The following units of service are billed on the appropriate claim form:

(1) Service: Child Health Screening; Unit: Completed comprehensive screening.

(2) Service: Interperiodic Child Health Screening; Unit: Completed interperiodic screening.

(3) Service: Child Health Encounter; Unit: per encounter; limited to 3 encounters per day.

(4) Service: Individual Treatment Encounter; Unit: 15 minutes, unless otherwise specified.

(A) Hearing and Vision Services.

(B) Speech Language Therapy; Unit: per session, limited to one per day.

(C) Physical Therapy.

(D) Occupational Therapy.

(E) Nursing Services; Unit: up to 15 minutes; maximum 32 units per day.

(F) Psychotherapy Services; maximum 8 units per day.

(G) Assistive Technology.

(H) Therapeutic Behavioral Services.

(5) Service: Group Treatment Encounter; no more than 5 members per group, Unit: 15 minutes, unless otherwise specified. A daily log/list must be maintained and must identify the SoonerCare participants for each group therapy session. 

(A) Hearing and Vision Services.

(B) Speech Language Therapy; Unit: per session, limited to one per day.

(C) Physical Therapy.

(D) Occupational Therapy.

(E) Psychotherapy Services; maximum 8 units per day.

(6) Service: Administration only, Immunization; Unit: one administration.

(7) Service: Hearing Evaluation; Unit: Completed Evaluation.

(8) Service: Hearing Aid Evaluation; Unit: Completed Evaluation.

(9) Service: Audiometric Test (Impedance); Unit: Completed Test (Both Ears).

(10) Service: Tympanometry and acoustic reflexes.

(11) Service: Ear Impression Mold; Unit: 2 molds (one per ear).

(12) Service: Vision Screening; Unit: one examination, by state licensed O.D., M.D., or D.O.

(13) Service: Speech Language Evaluation; Unit: one evaluation.

(14) Service: Physical Therapy Evaluation; Unit: one evaluation.

(15) Service: Occupational Therapy Evaluation; Unit: one evaluation.

(16) Service: Psychological Evaluation and Testing; Unit: one hour.

(17) Service: Personal Care Services; Unit: 10 minutes, 32 units daily.

(18) Service: Nursing Assessment/Evaluation (Acute episodic care); Unit: one assessment/evaluation, 18 yearly.

(19) Service: Psychological Evaluation and Testing; Unit: per hour of psychologist time, 8 hours yearly.

317:30-5-1028.Billing [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.