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Part 103      QUALIFIED SCHOOLS AS PROVIDERS OF HEALTH RELATED SERVICES

317:30-5-1020.General provisions
[Revised 09-12-14]

(a) Payment is made to eligible qualified school providers for delivery of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services to eligible individuals under the age of 21. School-based services must be medically necessary and have supporting documentation to be considered for reimbursement. In addition, services provided in the school setting are only compensable when provided to eligible SoonerCare members pursuant to an Individual Education Plan (IEP).  

(b) EPSDT services are comprehensive child-health services, designed to ensure the availability of, and access to, required health care resources and to help parents and guardians of SoonerCare eligible children use these resources.  Effective EPSDT services assure that health problems are diagnosed and treated early before they become more complex and their treatment more costly.  The Schools play a significant role in educating parents and guardians about all services available through the EPSDT program.

(c) The receipt of an identified EPSDT screening makes the SoonerCare child eligible for all necessary follow-up care that is within the scope of the SoonerCare Program.  An Individualized Education Program (IEP) or Individual Family Services Plan (IFSP) entitles the SoonerCare eligible child to medically necessary and appropriate health related EPSDT treatment services.  For reimbursement purposes, prior to rendering a medically related evaluation and/or service pursuant to an eligible SoonerCare child's IEP or IFSP, either through an IEP/IFSP addendum or a new IEP/IFSP, parental consent must be obtained. An IEP or IFSP serves as the plan of care for consideration of reimbursement for health related EPSDT treatment services. The IEP or IFSP may not serve as an evaluation. Services that require prior authorization will need to be authorized prior to the development of the IEP or IFSP. The IEP/IFSP must be completed and signed during the meeting by all required providers and individuals and must include the type, frequency, and duration of the service(s) provided, the signatures, including credentials, of the provider(s) and the direct care staff delivering services under the supervision of the professional, and the specific place of services if other than the school (e.g., field trip, home). The IEP/IFSP must also contain 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.  In order to bill SoonerCare for services rendered in the school, including evaluations, these services must result in or be identified in the IEP. Federal regulations require that diagnosis and treatment be provided for conditions identified during a screening whether or not they are covered under the Authority's current program.  Such services must be allowable under federal Medicaid regulations and must be necessary to ameliorate or correct defects of physical or mental illnesses/conditions.

(d) Federal regulations require that the State set standards and protocols for each component of EPSDT services.  The standards must provide for services at intervals which meet reasonable standards of medical and dental practice.  The standards must also provide for EPSDT services at other intervals as medically necessary to determine the existence of certain physical and mental illnesses or conditions.  SoonerCare providers who offer EPSDT screenings must assure that the screenings they provide meet the minimum standards for those services in order to be reimbursed at the level established for EPSDT services.

(e) To assure full payment for the EPSDT screening, providers must perform and document all necessary components of the screening examination.  Documentation of screening services performed must be retained for future review.

(f) Evaluations must be prior authorized when medically necessary and/or required and prescribed or referred by a treating physician or other practitioner of the healing arts with supporting medical documentation.  Initial evaluations (e.g. initial physical therapy evaluation) that do not require a prior authorization and that are performed as part of the IEP development process are compensable when the appropriate documented referral and supporting medical documentation are in place. Evaluations completed for educational purposes only are not compensable. All evaluations must be medically necessary and support the services billed to SoonerCare. The evaluations must be included in the IEP for reimbursement consideration. A diagnosis alone is not sufficient documentation to support the medical necessity of services. The child's diagnosis must clearly establish and support that the prescribed therapy is medically necessary. Evaluations must be completed annually and updated to accurately reflect the participant's current status. Evaluations include but are not limited to hearing and speech services, physical therapy, occupational therapy, and psychological evaluations and must include the following information:

(1) Medical documentation that supports why the member was referred for evaluation;

(2) Diagnosis;

(3) Member's strengths, needs, and interests;

(4) Recommended interventions for identified needs, including

outcomes and goals;

(5) Recommended units and frequency of services; and

(6) Dated signature and credentials of professional completing the evaluation.

(g) Annual evaluations/re-evaluations are required prior to each annual IEP.

(h) No more than five SoonerCare members can be present during a group therapy session. A daily log/list must be maintained and must identify the participants for each group session.
317:30-5-1021.Eligible providers
[Revised 09-12-14]

(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 amended in 1997.  A completed contract to provide EPSDT services through the schools must be submitted to the Oklahoma Health Care Authority (OHCA).  The OHCA must approve the contract in order for eligible school providers to receive reimbursement.
(b) Qualified Schools must notify OHCA of all subcontractors performing 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. OHCA may request that schools enroll with SoonerCare all entities and individuals that provide SoonerCare services in the school setting and may require that the rendering provider be included on any claim for payment by the school.

317:30-5-1022.Periodicity schedule
[Revised 09-12-14]

(a) The Oklahoma SoonerCare Program adopted the recommendations of the American Academy of Pediatrics for services, which include at least the following:

(1) Six screenings during the first year of life;

(2) Two screenings in the second year;

(3) One screening yearly for ages two through five years;

(4) One screening every other year for ages six through 20 years.

(b) Children 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 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-service activity.  Results of the child health screening are forwarded to the child's SoonerCare provider.
317:30-5-1023.Coverage by category
[Revised 09-12-14] 

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

(b) Children.  Payment is made for compensable services rendered by local, regional, and state educational services agencies as defined by IDEA:

(1) Child health screening.  An initial screening may be requested by an eligible individual at any time and must be provided without regard to whether the individual'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 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 weeks and a request has been made and documented by the school, the school may then furnish the EPSDT child health screening. Written notification must be mailed to the Soonercare member's PCP prior to the school's intent to furnish and bill for the screen. Results of this screening must be forwarded to the child'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 find activity pursuant to an IDEA requirement. There must be a documented referral in place that indicates the child 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:

(A) vision

(B) hearing

(C) dental

(D) a child 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

(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 adhere to guidelines found at OAC 317:30-5-676 and must be provided by a state licensed audiologist who:

(i) holds a certificate of clinical competence from the American Speech and Hearing Association; 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 the American Speech and Hearing Association; 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 American Speech and Hearing Association; 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 with speech or language disorders and the diagnosis and appraisal of specific speech and language services. Speech Language evaluations must adhere to guidelines found at OAC 317:30-5-676 and must be provided by state licensed speech language pathologist who:

(i) holds a certificate of clinical competence from the American Speech and Hearing Association; 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. Occupational Therapy evaluations must adhere to guidelines found at OAC 317:30-5-296.

(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 State Department of Education (SDE). Psychological evaluations and testing services must adhere to guidelines found at OAC 317:30-5-241.1 and 317:30-5-241.2.

(4) Child guidance treatment encounter.  A child guidance treatment encounter may occur through the provision of individual, family, or group treatment services to children 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 IEP or IFSP and may include the following:

(A) Hearing and Vision Services. Hearing and vision services must adhere to guidelines found at OAC 317:30-5-676 and 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 American Speech and Hearing Association; 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 American Speech and Hearing Association; 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 adhere to guidelines found at OAC 317:30-5-676 and 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 American Speech and Hearing Association; 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 child'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 adhere to guidelines found at OAC 317:30-5-296 and 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, correct health problems and assist in removing or modifying health related barriers and must be provided by a registered nurse or licensed practical nurse under supervision of a registered nurse.  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 child.  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 SDE, 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. Psychotherapy services must adhere to guidelines found at OAC 317:30-5-241.1 and 317:30-5-241.2.

(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 child and caregiver.  Services must be provided by a:

(i) state licensed, Speech Language Pathologist who:

(I) holds a certificate of clinical competence from the American Speech and Hearing Association; 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 SDE, or Personal Care Assistants, including Licensed Practical Nurses, 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 registered nurse or licensed practical nurse. Catheter insertion and Catheter/Ostomy care may only be reimbursed when done by a registered nurse or licensed practical nurse.

(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 State Department of Education and a training curriculum in behavioral interventions for Pervasive Developmental Disorders as recognized by OHCA. BHSA must be supervised by a bachelors level individual with a special education certification. BHSA must have CPR and First Aid certification. Six additional hours of related continuing education are required per year.

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

(c) Individuals 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.