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Part 11      PAYMENT, BILLING, AND OTHER ADMINISTRATIVE PROCEDURES

317:35-9-95.Payment to ICF/MR (public and private)

[Revised 09-01-16]
   The Oklahoma Health Care Authority may execute agreements to provide care only with facilities which are properly licensed by the state licensing agency. The agreement is initiated by application from the facility and expires on a specified date, or with termination of the facility license, or shall be automatically terminated on notice to OHCA that the facility is not in compliance with Medicaid (or other federal long-term care) requirements.

(1) In the event that a facility changes ownership, the agreement with the previous owner may be extended to the new owner, pending certification of the new owner to provide care to individuals during the change of ownership. In the event that the new owner is not showing good faith in pursuit of certification, the OHCA will begin planning for alternate placement of Medicaid patients. The county office is immediately notified of any relevant change in facility status.

(2) Payment for long-term care is made only for those individuals who have been approved by the DHS for such care. The amount of payment is based on the actual time the individual received care (including therapeutic/hospital leave) from a nursing facility during any given month. Payment for nursing care cannot be made for any period during which the care has been temporarily interrupted for reasons other than therapeutic leave. Therapeutic leave is any planned leave other than hospitalization that is for the benefit of the patient. Therapeutic leave must be clearly documented in the patient's plan of care before payment for a reserved bed can be made by the OHCA. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital.

(3) A nursing facility may receive payment for up to 7 days per calendar year for each eligible individual in order to reserve a bed when the patient is on therapeutic leave.

(4) The ICF/IID may receive payment for a maximum of 60 days of therapeutic leave per calendar year for each recipient to reserve a bed. No more than 14 consecutive days of therapeutic leave may be claimed per absence. Recipients approved for ICF/IID on or after July 1 of the year will only be eligible for 30 days of therapeutic leave during the remainder of that year.

(5) The Statement of Compensable Therapeutic Leave Only form is used by the facility to record use of therapeutic leave. This form is to be made available by the local office to the nursing facility upon request.

(6) No payment shall be made for hospital leave.

317:35-9-96.Non-Technical Medical Care providers; billing, training, and program administration [REVOKED]
[Revoked 6-26-00]

317:35-9-97.Payment for Home and Community Based Waiver services for the Intellectually Disabled (HCBW/ID)
[Revised 06-25-12]
Payment is made to HCBW/ID providers who have been certified as eligible to provide such services by the DHS Developmental Disabilities Services Division (DDSD). Certification is made after the provider has completed required training or meets the State licensing requirements for that medical discipline. Each provider must enter into a contract to provide HCBW/ID services. Payment is made on a procedure-based reimbursement methodology for each service. All services must be preauthorized before payment can be made.
317:35-9-98.Payment to mental health hospitals
[Issued 7-14-95]
Payment is made to mental health hospitals who have contracts with the Oklahoma Health Care Authority to provide inpatient mental health services. Mental health hospitals must be certified by Medicare before they are eligible to enter into a contract with the OHCA.

317:35-9-99.Billing procedures for ICF/MR, HCBW/MR services and services for individuals 65 older in a mental health hospital
[Revised 6-26-00]
Billing procedures for these services are contained in the OHCA Provider Manuals with procedures developed for each type of medical provider. Questions regarding billing procedures which cannot be resolved through a study of these manuals should be referred to the OHCA.

317:35-9-100.Management of client's funds while receiving care in NF, ICF/MR (public and private) or for persons age 65 or older in mental health hospitals
[Issued 7-14-95]
When an individual has been approved for long-term care in a facility, the administrator of the facility where he/she is receiving care completes the Management of Recipient's Funds form, and when applicable, the form is signed according to instructions on the form.
(1) If the recipient requests the administrator to hold the recipient's funds, the administrator of the facility completes the Management of Recipient's Funds form to acknowledge receipt of money and other items of value. As long as the recipient remains in the facility, the administrator is responsible for completing this form each time funds or other items of value, other than monthly income, are received. The form also serves to acknowledge the agreement to an accounting of funds expended in behalf of the recipient and as a source document for posting credits and debits to Form ABCDM-99, Ledger Sheet for Recipient's Account.
(2) The administrator of the facility prepares Form ABCDM-99 for each recipient for whom he/she is holding funds or other items of value. He/she is obligated to keep an accurate accounting of all receipts and expenditures and the amount of money on hand at all times. Form ABCDM-99 is to be available for inspection at all times.
(3) As a part of each redetermination of eligibility for a recipient for whom the administrator is holding funds or other items, the worker secures from the administrator a current Accounting-Recipient's Personal Funds and Property form. This form is also prepared by the administrator of the facility when the recipient dies or leaves the facility for some other reason and is routed to the county office within five days from the last day the recipient was in residence.
(4) If the facility operator does not handle the recipient's funds, the worker is responsible for determining who does handle the funds, the amount of the funds and for recording this in the case narrative.
(5) If there is indication that, prior to the next regular determination of eligibility, the amount of the recipient's resources is likely to increase or decrease, the worker is responsible for taking the necessary action to assure continued eligibility on the part of the recipient.
(6) A copy of the Management of Recipient's Funds form must be on file in the local office for each recipient for whom Title XIX funds are being used for payment of care.

317:35-9-101.Disclosure of information on health care providers and contractors
[Revised 6-26-00]
In accordance with the requirements of the Social Security Act and the regulations issued by the Secretary of Health and Human Services, the OHCA is responsible for disclosure of pertinent findings resulting from surveys made to determine eligibility of certain providers for ICF/MR (public and private) under Medicaid. In Oklahoma, the State Department of Health is the agency responsible for surveying ICF/MRs to obtain information for use by the Federal Government in determining whether these facilities meet the standards required for participation as Title XVIII (Medicare) and Medicaid providers.
(1) Following its survey of each facility, the State Department of Health sends a copy of pertinent materials, showing its findings, to the OHCA, Contract Services/Service Contract Operations, who forwards pertinent materials to the DHS county office in the county where such facility is located.
(2) Each county office is responsible for permitting anyone, who requests permission to do so, to inspect and/or copy such findings, if this is done within the county office. Such request to see these materials may be specifically related to one provider or may be a request to see the available survey materials on all providers. The requests need not be made in writing and the person making the request need sign no document in order to obtain access to the materials. No one can be given permission to take any of these materials from the county office.
(3) These materials are to be filed in an administrative file. Only the material requested by the individual is made available to him/her. The county administrator is responsible for devising a plan for assuring that all such survey material made available to an individual is returned by him/her before he/she leaves the office.
(4) When a new survey report is received on a facility, the former survey report on that facility is to be destroyed. A permanent file of survey reports is maintained in the OHCA.

317:35-9-102.Referral for social services

[Revised 6-26-00]
In many situations, social services are needed by adults who are receiving medical services through Medicaid. The LTC nurse may make referrals for social services to the worker in the local office by use of DHS Form K-13, Information/Referral Social Services. In addition to these referrals, a request for social services may be initiated by a client or by another individual acting upon behalf of a client.
(1) The worker is responsible for providing the indicated services or for referral to the appropriate resource outside the DHS if the services are not available within the DHS.
(2) Among the services provided by the worker are:
(A) Services which will enable individuals to attain and/or maintain as good physical and mental health as possible;
(B) Services to assist patients who are receiving care outside their own homes in planning for and returning to their own homes or to other alternate care;
(C) Services to encourage the development and maintenance of family and community interest and ties;
(D) Services to promote maximum independence in the management of their own affairs;
(E) Protective services, including evaluation of need for and arranging for guardianship; and
(F) Appropriate family planning services which include assisting the family in acquiring means to responsible parenthood. Services are offered in making the necessary referral and follow-up.

317:35-9-103.Special procedures for release of adults in mental health hospitals to long-term care facilities
[Revised 6-26-00]
(a) Procedures. Adult patients in state mental health hospitals being considered for release to long-term care facilities due to their physical conditions may be predetermined eligible for Medicaid.
(b) Responsibility of mental hospitals. The mental health hospital social and reimbursement staff works with the Social Security Administration to secure the approval for Supplemental Security Income (SSI) for individuals not currently eligible who may qualify for SSI. They will also assist the patient with the application for Medicaid medical services. By forwarding the completed Medical Assistance Application form and the Capital Resources Information form to the county office, the determination of financial eligibility by the DHS county worker can proceed at the same time that SSA is determining SSI eligibility. If the individual has other income (Social Security, VA, etc.) and does not qualify for SSI, the mental health hospital social and reimbursement staff evaluates the known resources. If the resources do not exceed the maximum as shown on the DHS Appendix C-1, Schedule VIII. D., individuals may be referred for a decision of eligibility for care in an intermediate care facility for the mentally retarded and, if necessary, categorical relationship. If the individual appears to meet the requirements as set out in this Subchapter, the mental health hospital social and reimbursement staff will submit a copy of the admitting history and physical progress notes, psychiatric examination and a physician's recommendation for a specific level of care, based on the individual's physical condition, to the Department of Mental Health and Substance Abuse Services, Central Office, Long-Term Care Division for review. If release to a long-term care facility appears appropriate, the medical information is submitted to LOCEU at the same time that the application forms are submitted to the county.
(c) Responsibility of LOCEU. The LOCEU reviews the hospital records, the social summary, the physician's recommendation for level of care as well as categorical relationship, if necessary. A Level II PASRR assessment is initiated by LOCEU at this point, if indicated. The MEDATS file is updated advising the DHS county office of LOCEU's decision.
(d) Responsibility of the DHS county office. The county office (in the county where the hospital is located) has the responsibility for the case number assignment, placing the case in application status and the subsequent determination of financial eligibility. The case is not certified until the patient enters an approved long-term care facility.
(1) Once the patient is determined financially and medically eligible a letter (including the assigned case number) is sent to the Department of Mental Health and Substance Abuse Services, Central Office, Long-Term Care Division.
(2) If the patient is determined to be ineligible, the denial is teleprocessed and a computer generated notice sent to the client or responsible person.
(e) Release from mental health hospital to a long-term care facility. After the hospital receives the letter from the county office with anticipated approval for Medicaid, the arrangements for release to the long-term care facility will proceed. The hospital will supply the long-term care facility with appropriate medical and social information and a copy of the DHS letter concerning the financial and medical eligibility.
(1) The long-term care facility, upon acceptance of the patient, forwards DHS form ABCDM-83, Notification Regarding Patient in a Nursing Facility, Intermediate Care Facility for the Mentally Retarded or Hospice (with the assigned case number) to the DHS county office where the long-term care facility is located.
(2) If the long-term care facility is in a different county than the hospital, the county of the facility requests the transfer of the case record. The certification is teleprocessed prior to the transfer of the case record.

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.