The RHC benefit package, as described in Title 42 of the Code of Federal Regulations (CFR), part 440.20, consists of two components: RHC Services and Other Ambulatory Services.
(1) RHC services. RHC services are covered when furnished to a member at the clinic or other location, including the member's place of residence. These services are described in this Section.
(A) Core services. As set out in Federal Regulations at 42 CFR 440.20(b), RHC "core" services include, but are not limited to:
(i) Physician's services;
(ii) Services and supplies incident to a physician's services;
(iii) Services of advanced practice nurses (APNs), physician assistants (PAs), nurse midwives (NMs) or specialized advanced practice nurse practitioners;
(iv) Services and supplies incident to the services of APNs and PAs (including services furnished by nurse midwives);
(v) Visiting nurse services to the homebound;
(vi) Clinical psychologist (CP) and clinical social worker (CSW) services;
(vii) Services and supplies incident to the services of CPs and CSWs.
(B) Physicians' services. In addition to the professional services of a physician, and services provided by an APN, PA and NMW which would be covered as RHC services under Medicare, certain primary preventive services are covered under the SoonerCare RHC benefit. The services must be furnished by or under the direct supervision of a RHC practitioner who is a clinic employee:
(i) prenatal and postpartum care;
(ii) screening examination under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program for members under 21;
(iii) family planning services;
(iv) medically necessary screening mammography and follow-up mammograms when medically necessary.
(C) Services and supplies "incident to". Services and supplies incident to the service of a physician, physician assistant, advanced practice nurse, clinical psychologist, or clinical social worker are covered if the service or supply is:
(i) a type commonly furnished in physicians' offices;
(ii) a type commonly rendered either without charge or included in the rural health clinic's bill;
(iii) furnished as an incidental, although integral, part of a physician's professional services;
(iv) Drugs and biologicals which cannot be self-administered or are specifically covered by Medicare law, are included within the scope of RHC services. Drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids are not billed separately.
(D) Visiting nurse services. Visiting nurse services are covered if:
(i) the RHC is located in an area in which the Centers for Medicare and Medicaid Services (CMS) has determined there is a shortage of home health agencies;
(ii) the services are rendered to members who are homebound;
(iii) the member is furnished nursing care on a part time or intermittent basis by a registered nurse, licensed practical nurse or licensed vocational nurse who is employed by or receives compensation for the services from the RHC; and
(iv) the services are furnished under a written plan of treatment.
(E) RHC encounter. RHC "core" services (including preventive services, i.e., prenatal, EPSDT or family planning) are part of an all-inclusive visit. A "visit" means a face-to-face encounter between a clinic patient and a RHC health professional (i.e., physicians, physician assistants, advanced practice nurses, nurse midwives, clinical psychologists and clinical social workers). Encounters with more than one health professional and multiple encounters with the same health professional that takes place on the same day and a single location, constitute a single visit except when the member, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. Payment is made for one encounter per member per day. Medical review will be required for additional visits for children. Payment is also limited to four visits per member per month for adults.
(F) Off-site services. RHC services provided off-site of the clinic are covered as long as the RHC has a compensation arrangement with the RHC practitioner that SoonerCare reimbursement is made to the RHC and the RHC practitioner receives his or her compensation from the RHC. The rural health clinic must have a written contract with the physician and other RHC "core" practitioners that specifically identify how the rural health clinic services provided off-site are to be billed to SoonerCare. It is expected that services provided in off-site settings are, in most cases, temporary and intermittent, i.e., when the member cannot come to the clinic due to health reasons.
(2) Other ambulatory services. A Rural Health Clinic must provide other items and services which are not "RHC services" as described in (a)(1) of this Section, and are separately billable to the SoonerCare program. Coverage of services are based upon the scope of coverage under the SoonerCare program.
(A) Other ambulatory services include, but are not limited to:
(i) dental services for members under age 21;
(ii) optometric services;
(iii) clinical lab tests performed in the RHC lab, including the lab tests required for RHC certification;
(iv) technical component of diagnostic tests such as x-rays and EKGs (interpretation of the test provided by the RHC physician is included in the encounter rate);
(v) durable medical equipment;
(vi) emergency ambulance transportation;
(vii) prescribed drugs;
(viii) prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags) and supplies directly related to colostomy care and the replacement of such devices;
(ix) specialized laboratory services furnished away from the clinic;
(x) inpatient services;
(xi) outpatient hospital services.
(B) Payment is made directly to the RHC on an encounter basis for on-site dental services by a licensed dentist or optometric services by a licensed optometrist for members under age 21. Encounters are billed as one of the following:
(i) EPSDT dental screening. An EPSDT dental screening includes oral examination, prophylaxis and fluoride treatment, charting of needed treatment, and, if necessary, x-rays (including two bite wing films). This service must be filed on claim form ADM-36-D for EPSDT reporting purposes.
(ii) Dental encounter. A dental encounter consists of all dental treatment other than a dental screening. This service must be billed on the ADM-36-D.
(iii) Visual analysis. Visual analysis (initial or yearly) for a child with glasses, or a child who needs glasses, or a medical eye exam. This includes the refraction and medical eye health evaluation. Glasses must be billed separately. Payment is limited to two glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.
(C) Services listed in (a)(2)(A), (v)-(viii), of this Section, furnished on-site, require separate provider agreements with the OHCA. Service item (a)(2)(A)(iii) does not require a separate contract when furnished on-site, however, certain conditions of participation apply. (Refer to OAC 317:30-5-361 for conditions.)
(D) Other ambulatory services provided off-site by independent practitioners (through subcontracting agreements or arrangements for services not available at the clinic) must be billed to the SoonerCare program by the provider rendering the service. Independent practitioners must meet provider eligibility criteria and must have a current contract with the OHCA.