Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.1 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Part,
					 have the following meaning, unless the context clearly indicates otherwise.
"Activities of daily living-basic"
means a
					 series of activities performed on a day-to-day basis that are necessary to care
					 for oneself (e.g., personal hygiene, dressing, eating, maintaining continence
					 and transferring).
"Activities of daily living-instrumental"
means activities that are not necessarily required on a daily basis but are
					 important to being able to live independently (e.g., basic communication
					 skills, transportation, meal preparation, shopping, housework, managing
					 medication and managing personal finances).
.
"Capped rental"
means monthly payments for the
					 use of the medical supplies, equipment, and appliances for a limited period of
					 time not to exceed thirteen (13) months. Items are considered purchased and
					 owned by the Oklahoma Health Care Authority (OHCA) after thirteen (13) months
					 of continuous rental.
"Certificate of medical necessity (CMN)"
means
					 a certificate which is required to help document the medical necessity and
					 other coverage criteria for selected items. Those items are defined in this
					 Chapter. The CMN must include the member's diagnosis, the reason the equipment
					 is required, and the physician's, non-physician provider's (NPP's), or
					 dentist's estimate, in months, of the duration of its need.
"Complex rehabilitation technology"
means
					 medically necessary durable medical equipment and items that are individually
					 configured to meet specific and unique medical, physical, and functional needs
					 and capacities for basic activities of daily living and instrumental activities
					 of daily living of a member with complex needs. Such equipment and items
					 include, but are not limited to, individually configured power wheelchairs and
					 accessories, individually configured manual wheelchairs and accessories,
					 adaptive seating and positioning systems and accessories, and other specialized
					 equipment such as standing frames and gait trainers.
"Customized equipment and/or appliances"
means
					 items of equipment and/or appliances which have been uniquely constructed or
					 substantially modified for a specific member according to the description and
					 orders of the member's treating physician or other qualified medical
					 professional. For instance, a wheelchair would be considered "customized" if it
					 has been:
(A) Measured, fitted, or adapted in consideration of the
					 member's body size, disability, period of need, or intended use;
(B) Assembled by a supplier or ordered from a manufacturer
					 who makes available customized features, modifications, or components for
					 wheelchairs; and
(C) Intended for an individual member's use in accordance
					 with instructions from the member's physician.
" Equipment and/or appliances"
means items
					 that are primarily and customarily used to serve a medical purpose, generally
					 are not useful to an individual in the absence of a disability, illness or
					 injury, can withstand repeated use, can be reusable or removable, and are
					 suitable for use in any setting in which normal life activities take place
					 other than a hospital, long-term care facility, intermediate care facility for
					 individuals with intellectual disabilities, or any setting in which payment is
					 or could be made under Medicaid for inpatient services that include room and
					 board. Refer to
					 42 Code of Federal Regulations (C.F.R.)
					 440.70(b).
"Face-to-face encounter"
means a patient visit
					 in which a practitioner, as defined by
					 42 C.F.R.
					 440.70(f), completes a
					 face-to-face assessment related to the primary reason the beneficiary requires
					 durable medical equipment. The face-to-face encounter must occur no more than
					 six (6) months prior to the start of services. The ordering physician must
					 document the face-to-face encounter, including the practitioner who conducted
					 the encounter and the date of the encounter. Clinical findings must be
					 incorporated into a written or electronic document included in the
					 beneficiary's medical record. The face-to-face encounter may occur through
					 telehealth.
"Invoice"
means a document that provides the
					 following information when applicable: the description of product, quantity,
					 quantity in box, purchase price, NDC, strength, dosage, provider, seller's name
					 and address, purchaser's name and address, and date of purchase. At times,
					 visit notes will be required to determine how much of the supply was expended.
					 When possible, the provider should identify the SoonerCare member receiving the
					 equipment or supply on the invoice.
"Medical supplies"
means health care related
					 items that are consumable or disposable, or cannot withstand repeated use by
					 more than one (1) individual, that are required to address an individual
					 medical disability, illness, or injury. Medical supplies do not include skin
					 care creams, cleansers, surgical supplies, or medical or surgical
					 equipment.
"OHCA CMN"
means a certificate required to
					 help document the medical necessity and other coverage criteria for selected
					 items. Those items are defined in this Chapter. The CMN must include the
					 member's diagnosis, the reason equipment is required, and the physician's,
					 NPP's, or dentist's estimate, in months, of the duration of its need. This
					 certificate is used when the OHCA requires a CMN and one(1) has not been
					 established by CMS.
"Orthotics"
means a device used to support,
					 align, prevent or correct deformities, protect a body function, improve the
					 function of movable body parts or to assist a dysfunctional joint.
"Patient with complex needs"
means an
					 individual with a diagnosis or medical condition that results in significant
					 loss of physical or functional needs and capacities.
"Prosthetics"
means an artificial substitute
					 which replaces all or part of a body organ or replaces all or part of the
					 function of a permanently inoperative, absent, or malfunctioning body part.
"Provider"
refers to the treating provider and
					 must be a physician [Medical Doctor (MD), or Doctor of Osteopathy, (DO)], a NPP
					 [Physician Assistant (PA), or Advanced Practice Registered Nurse (APRN)], or a
					 dentist [Doctor of Dental Surgery (DDS), or Doctor of Medicine in Dentistry
					 (DMD)].
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at
					 27 Ok Reg 453, eff 12-3-09 (emergency); Amended at 27 Ok Reg 942, eff
					 5-13-10