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Part 110      INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/US)

317:30-5-1085.General provisions

[Revised 09-01-16]
(a) Indian Health Services (IHS) provide health care to Certificate of Degree of Indian Blood (CDIB) eligible American Indian and Alaska Natives (AI/AN). The IHS is a division of the Department of Health and Human Services that administers a system of hospitals and Indian health outpatient services. Urban Indian Clinics are considered facilities of the IHS. Under the Indian Self-Determination Act, Public Law 93-638, as amended, Tribes may also provide health care to IHS eligible AI/ANs.

(b) The rules at OAC 317:30-3 apply to IHS, Tribal, and Urban Indian facilities. Additionally, unless otherwise stated, all other SoonerCare rules apply to IHS, Tribal, and Urban Indian facilities.


 

317:30-5-1086.Eligible I/T/U providers

[Revised 09-01-16]
   Indian Health Services, Tribal Programs, and Urban Indian Clinics (I/T/Us) are considered eligible for participation in the SoonerCare Program. To receive SoonerCare reimbursement, an I/T/U must be contracted as a provider with the Oklahoma Health Care Authority and appear on the IHS maintained listing of IHS-operated and Indian health care facilities under a 638 agreement. OHCA recognizes that I/T/Us are the payer of last resort, and are not considered creditable health insurance. It is the sole responsibility of the facility to petition IHS for placement on the list of facilities operating under a 638 agreement.

317:30-5-1087.Terms and definitions

[Revised 09-01-17]

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

(1) "American Indian/Alaska Native (AI/AN)" means an individual of Native American descent who has or is eligible for a Certificate of Degree of Indian Blood (CDIB) card.

(2) "Behavioral Health services" means professional medical services for the treatment of a mental health and/or substance use disorder.

(3) "CFR" means the Code of Federal Regulations.

(4) "CMS" means the Centers for Medicare and Medicaid Services.

(5) "Encounter" means a face to face contact between a health care professional and an IHS eligible SoonerCare member for the provision of medically necessary Title XIX or Title XXI covered services through an IHS or Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at midnight, as documented in the patient's record.

(6) "Licensed Behavioral Health Professional (LBHP)" means a licensed psychologist, licensed clinical social worker(LCSW), licensed marital and family therapist (LMFT), licensed professional counselor (LPC), licensed behavioral practitioner (LBP) or licensed alcohol and drug counselor (LADC).

(7) "OHCA" means the Oklahoma Health Care Authority.

(8) "OMB rate" means the Medicaid reimbursement rate negotiated between CMS and IHS. Inpatient and outpatient Medicaid reimbursement rates for I/T/Us are published annually in the Federal Register or Federal Register Notices. The outpatient rate is also known as the I/T/U encounter rate. The encounter rate is available only to I/T/U facilities that appear on the IHS maintained listing of IHS-operated and Indian health care facilities operating under a 638 agreement. It is the sole responsibility of the facility to petition IHS for placement on this list.

(9) "Physician" means a doctor of medicine or osteopathy legally authorized to practice medicine and surgery or who is a licensed physician employed by the Federal Government in an IHS facility or who provides services in a 638 Tribal Facility.

(10) "State Administering Agency (SAA)" is the Oklahoma Health Care Authority.

(11) "638 Tribal Facility" is a facility that is operated by a tribe or tribal organization and funded by Title I or Title III of the Indian Self Determination and Education Assistance Act (Public Law 93-638).

 

 

317:30-5-1088.I/T/U provider participation requirements

[Revised 09-01-16]
(a) I/T/Us must directly employ the services of legally credentialed professional staff that are authorized within their scope of practice under state law to provide the services for which claims are submitted to SoonerCare; or I/T/U Physicians may meet all requirements for employment by the Federal Government as a physician and be employed by the Federal Government in an IHS facility or affiliated with a 638 Tribal Facility.

(b) The facility is required to contract with OHCA all professional staff employed by the I/T/U. Participating I/T/Us are required to submit contracts for all practitioners working within the facility via Oklahoma's Electronic Provider Enrollment (EPE) web-based system. The reimbursement for services rendered at or on behalf of the I/T/U will be made to the facility.

(c) Only professional staff listed as eligible providers in OAC 317:30-5 are recognized by OHCA.

 

317:30-5-1089.I/T/U multiple sites

[Revised 09-01-16]
(a) I/T/Us may contract as a PCP/CM under SoonerCare Choice (See OAC 317:25-7-5).

(b) I/T/Us are required to contract with all facilities affiliated or owned by the I/T/U to be eligible for SoonerCare reimbursement.



317:30-5-1090.Provision of other health services outside of the I/T/U encounter

[Revised 09-01-17]

(a) Medically necessary SoonerCare covered services that are not included in the I/T/U outpatient encounter rate may be billed outside the encounter rate within the scope of the SoonerCare fee-for-service contract. The services will be reimbursed at the fee-for-service rate, and will be subject to any limitations, restrictions or prior authorization requirements. Examples of these services include but are not limited to:

(1) durable medical equipment;

(2) glasses;

(3) ambulance;

(4) home health [refer to OAC 317:30-5-546];

(5) inpatient practitioner services;

(6) non-emergency transportation [refer to OAC 317:35-3-2];

(7) behavioral health case management [refer to OAC 317:30-5-241.6];

(8) psychosocial rehabilitative services [refer to OAC 317:30-5-241.3]; and

(9) psychiatric residential treatment facility services [refer to OAC 317:30-5, Part 6, Inpatient Psychiatric Hospitals].

(b) If the I/T/U facility chooses to provide other SoonerCare State Plan covered health services which are not included in the I/T/U encounter definition, those service providers must be contracted with OHCA and bill for those services under their assigned provider number consistent with program coverage limitations and billing procedures described by the OHCA.

317:30-5-1091.Definition of I/T/U services

[Revised 09-01-16]
(a) As described in 42 CFR 136.11(a), the I/T/U services may include hospital and medical care, dental care, public health nursing, preventive care (including immunizations).

(b) Further, 42 CFR 136.11(c) allows that the scope and availability of I/T/U services will depend upon the resources of the facility.

(c) I/T/U services may be covered when furnished to a patient at the clinic or other location, including a mobile clinic, or the patient's place of residence. Provider contracts must meet the provider participation requirements found at OAC 317:30-5-1096.

(d) I/T/U outpatient encounters include but are not limited to:

(1) Physicians' services and supplies incidental to a physician's services;

(2) Within limitations as to the specific services furnished, a doctor of dentistry or oral surgery, a doctor of optometry, or a doctor of podiatry [Refer to Section 1861(r) of the Act for specific limitations];

(3) Services of advanced practice nurses (APNs), physician assistants (PAs), certified nurse midwives (CNMs), or specialized advanced practice nurse practitioners;

(4) Services and supplies incidental to the services of APNs and PAs (including services furnished by certified nurse midwives);

(5) Public health nursing services, within the scope of their licensure, include but are not limited to services in the following areas:

(A) Phlebotomy;

(B) Wound care;

(C) Public health education;

(D) Administration of immunizations;

(E) Administration of medication;

(F) Child health screenings meeting EPSDT criteria;

(G) Smoking and Tobacco Use Cessation Counseling;

(H) Prenatal, newborn and postpartum assessments, including case management services for first time mothers; and

(I) General health assessments and management of conditions such as tuberculosis, diabetes and hypertension.

(6) Visiting nurse services to the homebound;

(7) Behavioral health professional services and services and supplies incidental to the services of LBHPs; and

(8) Dental services.

317:30-5-1092.Services and supplies incidental to I/T/U outpatient encounters
[Issued 07-01-06]
Services and supplies incidental to the service of a physician, physician assistant, advanced practice nurse, clinical psychologist, or clinical social worker may be covered if the service or supply is:
(1) of a type commonly furnished in physicians' offices;
(2) of a type commonly rendered either without charge or included in the I/T/U's bill;
(3) furnished as an incidental, although integral, part of professional services furnished by a physician, nurse practitioner, physician assistant, nurse midwife, or specialized nurse practitioner;
(4) furnished under the direct, personal supervision of a nurse practitioner, physician assistant, nurse midwife, specialized nurse practitioner or a physician; and
(5) in the case of a service, furnished by a member of the I/T/U's health care staff who is an employee of the clinic.

317:30-5-1093.I/T/U visiting nurses services

[Revised 09-01-16]
(a) Visiting nurse services may be covered if:

(1) The services are rendered to a homebound individual who is permanently or temporarily confined to his or her place of residence because of a medical or health condition. The individual may be considered homebound if he or she leaves the place of residence infrequently. For this purpose, place of residence does not include a hospital or long term care facility; and

(2) The services are furnished by a registered nurse, licensed practical nurse, or licensed vocational nurse who is employed by, and receives compensation for the services from the I/T/U; and

(3) The services are furnished under a written plan of treatment that is:

(A) established and reviewed at least every 60 days by a supervising physician of the I/T/U or established by a nurse practitioner, physician assistant, nurse midwife, or specialized nurse practitioner and reviewed at least every 60 days by a supervising physician; and

(B) signed by the nurse practitioner, physician assistant, nurse midwife, specialized nurse practitioner, or the supervising physician of the clinic.

(b) The nursing care covered in this Section includes:

(1) Services that must be performed by a registered nurse, licensed practical nurse, or licensed vocational nurse if the safety of the patient can be assured in the home and the medically desired results achieved; and

(2) Personal care services, to the extent covered under Medicare as home health services. These services include helping the patient to bathe, to get in and out of bed, to exercise and to take medications.

(c) This benefit does not cover household and housekeeping services or other services that would constitute custodial care.

 

317:30-5-1094.Behavioral health services provided at I/T/Us

[Revised 09-01-17]

(a) Behavioral health services that are primary, preventive, and therapeutic and would be covered if provided in another setting may be provided by I/T/U providers. Services provided by an I/T/U (refer to OAC 317:30-5-241 for a description of services) must meet the same requirements as services provided by another provider. Services include:

(1) Mental Health and/or Substance Use Assessment/Evaluation and Testing;

(2) Service Plan Development;

(3) Crisis Intervention Services;

(4) Medication Training and Support;

(5) Individual/Interactive Psychotherapy;

(6) Group Psychotherapy; and

(7) Family Psychotherapy.

(b) Behavioral health professional therapy services are covered when provided in accordance with a documented individualized treatment plan, developed to treat the identified mental health and/or substance use disorder(s). Behavioral health services must be billed on an appropriate claim form using appropriate Current Procedural Terminology (CPT) procedure code and guidelines. The time indicated on the claim form must be the time actually spent with the member.

(c) In order to support access to mental health services, these services may be provided in settings outside of the I/T/U. Offsite services must take place in a confidential setting.

(d) The outpatient behavioral health services' provider enrollment and reimbursement process in no way changes the OHCA's policy with regard to reimbursement of practitioners. Licensed clinical social workers (LCSW), licensed marital and family therapists (LMFT), licensed professional counselors (LPC), licensed behavioral practitioners (LBP), licensed alcohol and drug counselors (LADC), and licensure candidates are not eligible for direct reimbursement as practitioners. Their services are compensable only when billed by their employers and when provided in those clinical settings in which they are currently approved to render services. Licensure candidates must meet the requirements contained in OAC 317:30-5-240.3.

(e) For the provision of behavioral health related case management services, I/T/U providers must meet the requirements found at OAC 317:30-5-241.6, and be contracted as such. The provision of these services is considered to be outside of the I/T/U encounter. Contracted behavioral health case management providers are responsible for obtaining all necessary prior authorizations, if needed, and will be paid at the current fee-for-service rate.

(f) For the provision of psychosocial rehabilitation services, I/T/U facilities meet the requirements found at OAC 317:30-5-241.3, and must contract as an outpatient behavioral health agency. The provision of these services is considered to be outside of the I/T/U encounter. Contracted psychosocial rehabilitation service providers are responsible for obtaining all necessary prior authorizations, if needed, and will be paid at the current fee-for-service rate.

317:30-5-1095.I/T/U services not compensable under outpatient encounters

[Revised 09-01-16]
   I/T/U services that are not compensable under outpatient encounters include:

(1) group or mass information programs, health education classes, or group education activities, including media productions and publications;

(2) vaccines covered by the Vaccines for Children program [refer to OAC 317:30-5-14(a)(1)];

(3) group or sports physicals and medical reports;

(4) drug samples or other prescription drugs provided to the clinic free of charge;

(5) administrative medical examinations and report services; and

(6) gauze, band-aids, or other disposable products used during an office visit.

 

317:30-5-1096.I/T/U off-site services

[Revised 09-01-16]
   I/T/U covered services provided off-site or outside of the I/T/U setting, including mobile clinics or places of residence, are compensable when billed by the I/T/U. The I/T/U must meet provider participation requirements listed in 317:30-5-1088. I/T/U off-site services may be covered if the services rendered were within the provider's scope of practice and are of the same integrity of services rendered at the I/T/U facility.

317:30-5-1097.Billable I/T/U encounters
[Issued 07-01-06]
I/T/U encounters that are billed to the OHCA must meet the definition listed in OAC 317:30-5-1099 and are limited to medically necessary State Plan services covered by OHCA. These services include ambulatory services included in the State Plan under Title XIX or Title XXI of the Social Security Act.

317:30-5-1098.I/T/U outpatient encounters

[Revised 09-01-17]

(a) I/T/U outpatient encounters that are billed to the OHCA must meet the definition in this Section and are limited to services covered by the OHCA. These services include health services included in the State Plan under Title XIX or Title XXI of the Social Security Act.

(1) An I/T/U encounter means a face to face or telehealth contact between a health care professional and an IHS eligible SoonerCare member for the provision of medically necessary Title XIX or Title XXI covered services through an IHS or Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at midnight, as documented in the patient's record.

(2) An I/T/U outpatient encounter means outpatient services that may be covered when furnished to a patient by a contracted SoonerCare provider employed by the I/T/U facility and rendered at the I/T/U facility or other location, including the patient's place of residence.

(b) The following services may be considered reimbursable encounters subject to the limitations of the Oklahoma State Plan and include any related medical supplies provided during the course of the encounter:

(1) Medical;

(2) Diagnostic;

(3) Behavioral Health services [refer to OAC 317:30-5-1094];

(4) Dental, Medical and Mental Health Screenings;

(5) Vision;

(6) Physical Therapy;

(7) Occupational Therapy;

(8) Podiatry;

(9) Speech;

(10) Hearing;

(11) Visiting Nurse Service [refer to OAC 317:30-5-1093];

(12) Smoking and Tobacco Use Cessation Counseling;

(13) Other Title XIX or XXI services as allowed under OHCA's SoonerCare State Plan and OHCA Administrative Rules;

(14) Drugs or medication treatments provided during a clinic visit are part of the encounter rate. For example, a member has come into the clinic with high blood pressure and is treated at the clinic with a hypertensive drug or drug sample. Drug samples are included in the encounter rate. Prescription drugs are reimbursed pursuant to OAC 317:30-5-78(b)(4)(B).

(15) Encounters with a registered professional nurse or a licensed practical nurse and related medical supplies (other than drugs and biologicals) furnished on a part-time or intermittent basis to home-bound members; and

(16) I/T/U Multiple Outpatient Encounters.

(A) OHCA will cover one medically necessary outpatient medical encounter per member per day unless if due to an emergency, the same member returns on the same day for a second visit with a different diagnosis. Then, a second encounter is allowed.

(B) OHCA will cover one dental encounter per member per day regardless of how many procedures are done or how many providers are seen unless if due to an emergency, the same member returns on the same day for a second visit and has a different diagnosis. Then, a second encounter is allowed.

(C) OHCA will cover one behavioral health professional outpatient encounter per member per day unless if due to an emergency, the same member returns on the same day for a second visit and has a different diagnosis. Then, a second encounter is allowed.

(D) Each service must have distinctly different diagnoses in order to meet the criteria for multiple I/T/U outpatient encounters.

(c) More than one outpatient visit with a medical professional within a 24-hour period for distinctly different diagnoses may be reported as two encounters. This does not imply that if a member is seen at a single office visit with multiple problems that multiple encounters can be billed. For example, a member comes to the clinic in the morning for an immunization, and in the afternoon, the member falls and breaks an arm. This would be considered multiple medical encounters and can be billed as two encounters. However, a member who comes to the I/T/U facility for a diabetic wellness screening and is then referred to a podiatrist within the clinic for diabetes-related follow-up on the same date of service would not be considered a distinctly different diagnosis and can only be billed as a single encounter.

(d) The following services may be considered as separate or multiple encounters when two or more services are provided on the same date of service with distinctly different diagnoses:

(1) Medical Services;

(2) Dental Services;

(3) Mental Health and addiction services with similar diagnoses can only be billed as one encounter. In addition, if the member is also seen for a medical office visit with a mental health or addiction diagnosis, then it is considered a single encounter;

(4) Physical or occupational therapy (PT/OT). If this service is also performed on the same date of service as the medical encounter that determined the need for PT/OT (initial referral), then it is considered a single encounter;

(5) Administration of immunizations. If no other medical office visit occurs on the same date of services; and

(6) Tobacco cessation limited to state plan services. If no other medical or addiction encounter occurs on the same date of service.

(e) I/T/U outpatient encounters for IHS eligible SoonerCare members whether medical, dental, or behavioral health, are not subject to prior authorization. Other State Plan covered services that the I/T/U facility chooses to provide but which are not part of the I/T/U encounter are subject to all applicable SoonerCare regulations which govern the provision and coverage for that service.

 
317:30-5-1099.I/T/U service limitations

[Revised 09-01-16]
   Service limitations governing the provision of all Oklahoma SoonerCare services will apply pursuant to Chapter 30 of the OHCA rules. In addition, the following limitations and requirements apply to services provided by I/T/U facilities:

(1) Multiple encounters. An I/T/U facility may bill for more than one encounter per 24 hour period under certain conditions.

(2) Behavioral Health services. Behavioral Health Services are limited to those services furnished to members at or on behalf of the I/T/U facility.

(3) Laboratory procedures. Laboratory procedures performed by an I/T/U outpatient facility (not an independently certified enrolled laboratory) on the same date of service are considered part of the health care practitioner's service and are included in the I/T/U encounter.


 

317:30-5-1100.Inpatient care provided by IHS facilities

[Revised 09-01-16]
   Inpatient practitioner services are separately contracted and paid at a fee-for-service rate. Each individual inpatient practitioner must be contracted with SoonerCare and attached to a SoonerCare contracted medical group. The Inpatient hospital per diem rate for inpatient medical care provided by IHS facilities is published annually in the Federal Register or Federal Register Notices. In order to receive the inpatient hospital per diem rate, the IHS or Tribal 638 facility must:

(1) be contracted as a provider with the Oklahoma Health Care Authority; and

(2) appear on the IHS maintained listing of IHS-operated and Indian health care facilities operating under a 638 agreement. It is the sole responsibility of the facility to petition IHS for placement on this list.

 

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.