OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

317:30-5-1020.General provisions
[Revised 09-12-14]

(a) Payment is made to eligible qualified school providers for delivery of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services to eligible individuals under the age of 21. School-based services must be medically necessary and have supporting documentation to be considered for reimbursement. In addition, services provided in the school setting are only compensable when provided to eligible SoonerCare members pursuant to an Individual Education Plan (IEP).  

(b) EPSDT services are comprehensive child-health services, designed to ensure the availability of, and access to, required health care resources and to help parents and guardians of SoonerCare eligible children use these resources.  Effective EPSDT services assure that health problems are diagnosed and treated early before they become more complex and their treatment more costly.  The Schools play a significant role in educating parents and guardians about all services available through the EPSDT program.

(c) The receipt of an identified EPSDT screening makes the SoonerCare child eligible for all necessary follow-up care that is within the scope of the SoonerCare Program.  An Individualized Education Program (IEP) or Individual Family Services Plan (IFSP) entitles the SoonerCare eligible child to medically necessary and appropriate health related EPSDT treatment services.  For reimbursement purposes, prior to rendering a medically related evaluation and/or service pursuant to an eligible SoonerCare child's IEP or IFSP, either through an IEP/IFSP addendum or a new IEP/IFSP, parental consent must be obtained. An IEP or IFSP serves as the plan of care for consideration of reimbursement for health related EPSDT treatment services. The IEP or IFSP may not serve as an evaluation. Services that require prior authorization will need to be authorized prior to the development of the IEP or IFSP. The IEP/IFSP must be completed and signed during the meeting by all required providers and individuals and must include the type, frequency, and duration of the service(s) provided, the signatures, including credentials, of the provider(s) and the direct care staff delivering services under the supervision of the professional, and the specific place of services if other than the school (e.g., field trip, home). The IEP/IFSP must also contain measurable goals for each of the identified needs. Goals must be updated to reflect the current therapy, evaluation, or service that is being provided and billed to SoonerCare.  In order to bill SoonerCare for services rendered in the school, including evaluations, these services must result in or be identified in the IEP. Federal regulations require that diagnosis and treatment be provided for conditions identified during a screening whether or not they are covered under the Authority's current program.  Such services must be allowable under federal Medicaid regulations and must be necessary to ameliorate or correct defects of physical or mental illnesses/conditions.

(d) Federal regulations require that the State set standards and protocols for each component of EPSDT services.  The standards must provide for services at intervals which meet reasonable standards of medical and dental practice.  The standards must also provide for EPSDT services at other intervals as medically necessary to determine the existence of certain physical and mental illnesses or conditions.  SoonerCare providers who offer EPSDT screenings must assure that the screenings they provide meet the minimum standards for those services in order to be reimbursed at the level established for EPSDT services.

(e) To assure full payment for the EPSDT screening, providers must perform and document all necessary components of the screening examination.  Documentation of screening services performed must be retained for future review.

(f) Evaluations must be prior authorized when medically necessary and/or required and prescribed or referred by a treating physician or other practitioner of the healing arts with supporting medical documentation.  Initial evaluations (e.g. initial physical therapy evaluation) that do not require a prior authorization and that are performed as part of the IEP development process are compensable when the appropriate documented referral and supporting medical documentation are in place. Evaluations completed for educational purposes only are not compensable. All evaluations must be medically necessary and support the services billed to SoonerCare. The evaluations must be included in the IEP for reimbursement consideration. A diagnosis alone is not sufficient documentation to support the medical necessity of services. The child's diagnosis must clearly establish and support that the prescribed therapy is medically necessary. Evaluations must be completed annually and updated to accurately reflect the participant's current status. Evaluations include but are not limited to hearing and speech services, physical therapy, occupational therapy, and psychological evaluations and must include the following information:

(1) Medical documentation that supports why the member was referred for evaluation;

(2) Diagnosis;

(3) Member's strengths, needs, and interests;

(4) Recommended interventions for identified needs, including

outcomes and goals;

(5) Recommended units and frequency of services; and

(6) Dated signature and credentials of professional completing the evaluation.

(g) Annual evaluations/re-evaluations are required prior to each annual IEP.

(h) No more than five SoonerCare members can be present during a group therapy session. A daily log/list must be maintained and must identify the participants for each group session.

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.