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317:25-7-2.SoonerCare Choice: overview
[Revised 01-01-09]
(a) The Oklahoma Health Care Authority (OHCA) operates a Primary Care Case Management (PCCM) system for SoonerCare Choice eligible members.  PCCM is a managed care model in which each enrollee has a medical home with a primary care provider (PCP).  Enrollees may select their own primary care provider or clinic as their PCP if that provider is enrolled with OHCA as a PCP and as a SoonerCare provider.  For those who do not choose a PCP, they will be assigned to one.  Members may change PCPs at any time.
(b) The PCP is paid a monthly care coordination payment in accordance with the conditions in the PCP's SoonerCare Choice contract to provide or otherwise assure the delivery of medically-necessary preventive and primary care medical services, including securing referrals for specialty services and prior authorizations for an enrolled group of eligible members, with the exception of services described in subsection (c) of this Section for which authorization is not required.  The PCP assists the member in gaining access to the health care system and monitors the member's condition, health care needs and service delivery.
(c) Services which do not require a referral from the PCP include preventive or primary care services rendered by another SoonerCare contracted provider, outpatient behavioral health agency services, vision services for children, dental services, child abuse/sexual abuse examinations, prenatal and obstetrical services, family planning services, emergency physician and hospital services, disease management services, and services delivered to Native Americans at IHS, tribal, or urban Indian clinics.  Female members may access a SoonerCare women's health specialist without a referral for covered routine and preventive health care services.  This is in addition to the enrollee's PCP if that source is not a woman's health specialist.
(d) SoonerCare Choice covered services delivered by the PCP are reimbursed at the SoonerCare fee schedule rate under the procedure code established for each individual service.  To the extent services are provided or authorized by the Primary Care Provider, the OHCA does not make SoonerCare Choice payments for services delivered outside the scope of coverage of the SoonerCare Choice program, thus a referral by the PCP does not guarantee payment.
(e) The PCP may charge a co-payment for services provided to SoonerCare members in accordance with OAC 317:30-3-5(d).
(f) Members with chronic conditions may elect to enroll in a health management program to improve their health.
(g) PCPs may elect to participate in Health Access Networks to improve access to care.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.