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317:25-7-5.Primary care providers
[Revised 09-01-16]

For provision of health care services, the OHCA contracts with qualified Primary Care Providers. All providers serving as PCPs must have a valid SoonerCare Fee-for-Service contract as well as an exercised SoonerCare Choice addendum. Additionally, all PCPs, excluding Provider or Physician Groups, must agree to accept a minimum capacity of patients, however this does not guarantee PCPs a minimum patient volume. Primary Care Providers are limited to:

(1) Physicians. Any physician licensed to practice medicine in the state in which he or she practices who is engaged in a general practice or in family medicine, general internal medicine or general pediatrics may serve as a PCP. The Chief Executive Officer (CEO) of the OHCA may designate physicians to serve as PCPs who are licensed to practice medicine in the state in which they practice who are specialized in areas other than those described above. In making this determination, the CEO may consider such factors as the percentage of primary care services delivered in the physician's practice, the availability of primary care providers in the geographic area of the state in which the physician's practice is located, the extent to which the physician has historically provided services to SoonerCare members, and the physician's medical education and training.

(A) For physicians serving as SoonerCare Choice PCPs, the State caps the number of members per physician at 2,500. However, the CEO in his/her discretion may increase this number in under served areas based on a determination that this higher cap is in conformance with usual and customary standards for the community. If a physician practices at multiple sites, the capacity at each site is determined based on the number of hours per week the physician holds office hours, not to exceed one FTE. Thus, the physician cannot exceed a maximum total capacity of 2500 members.

(B) In areas of the State where cross-state utilization patterns have developed because of limited provider capacity in the State, the CEO may authorize contracts with out-of-state providers for PCP services. Out-of-State PCPs are required to comply with all access standards imposed on Oklahoma physicians.

(2) Advanced Practice Nurses. Advanced Practice Nurses who have prescriptive authority may serve as PCPs for the Primary Care Case Management delivery system if licensed to practice in the state in which he or she practices. Advanced Practice Nurses who have prescriptive authority may serve as PCPs for a maximum number of 1,250 members. However, the CEO in his/her discretion may increase this number.

(3) Physician Assistants. Physician Assistants may serve as PCPs if licensed to practice in the state in which he or she practices.  Physician Assistants may serve as PCPs for a maximum number of 1,250 members. However, the CEO in his/her discretion may increase this number.

(4) Indian Health Service (IHS) Facilities and Federally Qualified Health Center (FQHC) provider groups.

(A) Indian Health Service facilities whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements at OAC 317:30-5-1088 may serve as PCPs.

(B) Federally Qualified Health Centers whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements in OAC 317:30-5-660.2 may serve as PCPs.

(5) Provider or physician group capacity and enrollment.

(A) Provider or physician groups must agree to accept a minimum enrollment capacity and may not exceed 2,500 members per physician participating in the provider group.

(B) If licensed physician assistants or advanced practice nurses are members of a group, the capacity may be increased by 1,250 members if the provider is available full-time.
(C) Provider or physician groups must designate a medical director to serve as the primary contact with OHCA.

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.