Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 21 - OUTPATIENT BEHAVIORAL HEALTH AGENCY SERVICES › Section 317:30-5-241 - Covered Services

Current through Vol. 41, No. 20, July 1, 2024
(a) Outpatient
				  behavioral health services are covered for adults and children as set forth in
				  this Section when provided in accordance with a documented individualized
				  service plan, developed to treat the identified behavioral health and/or
				  substance use disorder(s), unless specified otherwise.
(b) All services are to be for the goal of
				  improvement of functioning, independence, or well-being of the member. The
				  services and service plans are to be recovery focused, trauma and co-occurring
				  specific. The member must be able to actively participate in the treatment.
				  Active participation means that the member must have sufficient cognitive
				  abilities, communication skills, and short-term memory to derive a reasonable
				  benefit from the treatment.
(c) In
				  order to be reimbursed for services, providers must submit a completed Customer
				  Data Core (CDC) to OHCA or its designated agent. The CDC must be reviewed,
				  updated and resubmitted by the provider every six months. Reimbursement is made
				  only for services provided while a current CDC is on file with OHCA or its
				  designated agent. For further information and instructions regarding the CDC,
				  refer to the Prior Authorization Manual .
(d) All outpatient BH services must be
				  provided following established medical necessity criteria. Some outpatient
				  behavioral health services may require authorization. For information regarding
				  services requiring authorization and the process for obtaining them, refer to
				  the Prior Authorization Manual . Authorization of services is not a guarantee
				  of payment. The provider is responsible for ensuring that the eligibility,
				  medical necessity, procedural, coding, claims submission, and all other state
				  and federal requirements are met. OHCA does retain the final administrative
				  review over both authorization and review of services as required by
				  42 CFR
				  431.10.
(e) Services to nursing facility residents.
				  Reimbursement is not allowed for outpatient behavioral health services provided
				  to members residing in a nursing facility. Provision of these services is the
				  responsibility of the nursing facility and reimbursement is included within the
				  rate paid to the nursing facility for the member's care.
(f) Services to members during an inpatient
				  stay. Unless otherwise specified in rules, reimbursement is not allowed for
				  outpatient behavioral health services provided to members who are considered to
				  be in "inpatient status" as defined in OAC
				  317:30-5-41.
(g) In addition to individual
				  service limitations, reimbursement for outpatient behavioral health services is
				  limited to 35 hours per rendering provider per week. Service hours will be
				  calculated using a rolling four week average. Services not included in this
				  limitation are:
(1) Assessments;
(2) Testing;
(3) Service plan development; and
(4) Crisis intervention services.