reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 109 - DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT › Section 317:30-5-1080 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms, when used in this Part,
					 shall have the following meaning, unless the context clearly indicates
					 otherwise:
"ADA"
means American Diabetes
					 Association.
"ADCES"
means the Association of Diabetes Care
					 and Education Specialists.
"BC-ADM"
means Board-certified advanced
					 diabetes management.
" CDCES"
means certified diabetes care and
					 education specialist.
" DSMES"
means diabetes self-management
					 education and support.
"OAC"
means Oklahoma Administrative
					 Code.
"OHCA"
means Oklahoma Health Care
					 Authority.
"Qualified non-physician provider"
means a
					 physician assistant or advanced practice registered nurse.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 109 - DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT › Section 317:30-5-1081 - Eligible providers and requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) In order to receive Medicaid
				  reimbursement for DSMES services, providers or provider groups must:
(1) Be working under an accredited DSMES
				  program that meets the quality standards of one (1) of the following
				  accreditation organizations:
(A) The ADA;
				  or
(B) The ADCES.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 109 - DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT › Section 317:30-5-1082 - Scope of services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General
				  provisions.
The OHCA covers medically necessary DSMES services when all
				  the following criteria are met:
(1) The
				  member has been diagnosed with diabetes by a physician or qualified
				  non-physician provider working within the scope of his/her licensure;
(2) The services have been ordered by a
				  physician or qualified non-physician provider who is actively managing the
				  member's diabetes;
(3) The services
				  are provided by a qualified DSMES provider [Refer to OAC 317:30-5-1081(a) (2)];
				  and
(4) The program meets the
				  current ADA or ADCES training standards.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 109 - DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT › Section 317:30-5-1083 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
The purpose of DSMES services must be to provide the
					 member with the knowledge, skill, and ability necessary for diabetes
					 self-care.
(1)
Adults.
Payment is made for medically necessary DSMES provided by eligible providers
				  described in OAC 317:30-5-1081. Refer to OAC 317:30-5-1082 for units of DSMES
				  training allowed.
(2)
Children/adolescents.
Payment is made for medically necessary
				  DSMES for members under twenty-one (21) years of age provided by eligible
				  providers described in OAC 317:30-5-1081. DSMES coverage for children is the
				  same as for adults. Additional DSMES services may be covered under EPSDT
				  provisions if determined to be medically necessary.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 109 - DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT › Section 317:30-5-1084 - Reimbursement methodology

Current through Vol. 41, No. 20, July 1, 2024
SoonerCare shall provide reimbursement for DSMES services
					 as follow:
(1) Payment shall be made
				  to fully-contracted providers. If the rendering provider operates through an
				  enrolled SoonerCare provider, or is contracted to provide services by an
				  enrolled SoonerCare provider, payment may be made to that enrolled SoonerCare
				  provider.
(2) Reimbursement for
				  DSMES services is only made on a fee-for-service basis. The maximum allowable
				  fee for a unit of service has been determined by OHCA to be a reasonable fee,
				  consistent with efficiency, economy, and quality of care. Payment for covered
				  services is the lower of the provider's actual billed charges, consistent with
				  the provider's usual and customary charge to the general public for the
				  service, or the maximum allowable per unit of service.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1085 - General provisions

Current through Vol. 41, No. 20, July 1, 2024
(a) Indian
				  Health Services (IHS) provide health care to Certificate of Degree of Indian
				  Blood (CDIB) eligible American Indian and Alaska Natives (AI/AN). The IHS is a
				  division of the Department of Health and Human Services that administers a
				  system of hospitals and Indian health outpatient services. Urban Indian Clinics
				  are considered facilities of the IHS. Under the Indian Self-Determination Act,
				  Public Law 93-638, as amended, Tribes may also provide health care to IHS
				  eligible AI/ANs.
(b) The rules at
				  OAC 317:30-3 apply to IHS, Tribal, and Urban Indian facilities. Additionally,
				  unless otherwise stated, all other SoonerCare rules apply to IHS, Tribal, and
				  Urban Indian facilities.
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1086 - Eligible I/T/U providers

Current through Vol. 41, No. 20, July 1, 2024
Indian Health Services, Tribal Programs, and Urban Indian
					 Clinics (I/T/US) are considered eligible for participation in the SoonerCare
					 Program. To receive SoonerCare reimbursement, an I/T/U must be contracted as a
					 provider with the Oklahoma Health Care Authority and appear on the IHS
					 maintained listing of IHS-operated and Indian health care facilities under a
					 638 agreement. OHCA recognizes that I/T/US are the payer of last resort, and
					 are not considered creditable health insurance. It is the sole responsibility
					 of the facility to petition IHS for placement on the list of facilities
					 operating under a 638 agreement.
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1087 - Terms and 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:
(1)
"American Indian/Alaska Native
				  (AI/AN)"
means an individual of Native American descent who has or is
				  eligible for a Certificate of Degree of Indian Blood (CDIB) card.
(2)
"Behavioral Health services"
means professional medical services for the treatment of a mental health and/or
				  substance use disorder.
(3)
"CFR"
means the Code of Federal Regulations.
(4)
"CMS"
means the Centers for
				  Medicare and Medicaid Services.
(5)
"Encounter"
means a face to
				  face contact between a health care professional and an IHS eligible SoonerCare
				  member for the provision of medically necessary Title XIX or Title XXI covered
				  services through an IHS or Tribal 638 facility or an urban Indian clinic within
				  a 24-hour period ending at midnight, as documented in the patient's record.
(6)
"Licensed Behavioral
				  Health Professional (LBHP)"
means a licensed psychologist, licensed
				  clinical social worker(LCSW), licensed marital and family therapist (LMFT),
				  licensed professional counselor (LPC), licensed behavioral practitioner (LBP)
				  or licensed alcohol and drug counselor (LADC).
(7)
"OHCA"
means the Oklahoma
				  Health Care Authority.
(8)
"OMB rate"
means the Medicaid reimbursement rate negotiated
				  between CMS and IHS. Inpatient and outpatient Medicaid reimbursement rates for
				  I/T/Us are published annually in the Federal Register or Federal Register
				  Notices. The outpatient rate is also known as the I/T/U encounter rate. The
				  encounter rate is available only to I/T/U facilities that appear on the IHS
				  maintained listing of IHS-operated and Indian health care facilities operating
				  under a 638 agreement. It is the sole responsibility of the facility to
				  petition IHS for placement on this list.
(9)
"Physician"
means a doctor
				  of medicine or osteopathy legally authorized to practice medicine and surgery
				  or who is a licensed physician employed by the Federal Government in an IHS
				  facility or who provides services in a 638 Tribal Facility.
(10)
"State Administering Agency
				  (SAA)"
is the Oklahoma Health Care Authority.
(11)
"638 Tribal Facility"
is a
				  facility that is operated by a tribe or tribal organization and funded by Title
				  I or Title III of the Indian Self Determination and Education Assistance Act (
				  Public Law 93-638 ).
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1088 - I/T/U provider participation requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) I/T/US must directly employ the services
				  of legally credentialed professional staff that are authorized within their
				  scope of practice under state law to provide the services for which claims are
				  submitted to SoonerCare; or I/T/U Physicians may meet all requirements for
				  employment by the Federal Government as a physician and be employed by the
				  Federal Government in an IHS facility or affiliated with a 638 Tribal Facility.
(b) The facility is required to
				  contract with OHCA all professional staff employed by the I/T/U. Participating
				  I/T/Us are required to submit contracts for all practitioners working within
				  the facility via Oklahoma's Electronic Provider Enrollment (EPE) web-based
				  system. The reimbursement for services rendered at or on behalf of the I/T/U
				  will be made to the facility.
(c)
				  Only professional staff listed as eligible providers in OAC 317:30-5 are
				  recognized by OHCA.
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1089 - I/T/U multiple sites

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  I/T/US may contract as a PCP/CM under SoonerCare Choice (See OAC
				  317:25-7-5
				  ).
(b) I/T/US are required to
				  contract with all facilities affiliated or owned by the I/T/U to be eligible
				  for SoonerCare reimbursement.
Added at 23 Ok Reg
					 2575, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1090 - Provision of other health services outside of the I/T/U encounter

Current through Vol. 41, No. 20, July 1, 2024
(a) Medically
				  necessary SoonerCare covered services that are not included in the I/T/U
				  outpatient encounter rate may be billed outside the encounter rate within the
				  scope of the SoonerCare fee-for-service (FFS) contract. The services will be
				  reimbursed at the FFS rate, and will be subject to any limitations,
				  restrictions, or prior authorization requirements. Examples of these services
				  include, but are not limited to:
(1) Durable
				  medical equipment [refer to Oklahoma Administrative Code (OAC)
				  317:30-5-210]
				  ;
(2) Eyeglasses (refer to OAC
				  317:30-5-431,
				  317:30-5-432.1
				  and
				  317:30-5-451);
(3) Transportation by ambulance (refer to OAC
				  317:30-5-335);
(4) Home health (refer to OAC
				  317:30-5-546);
(5) Inpatient practitioner services (refer to
				  OAC
				  317:30-5-1100);
(6) Non-emergency transportation (refer to
				  OAC
				  317:30-5-326
				  through
				  317:30-5-327.9);
(7) Behavioral health case management (refer
				  to OAC
				  317:30-5-241.6);
(8) Psychosocial rehabilitative services
				  (refer to OAC
				  317:30-5-241.3);
(9) Psychiatric residential treatment
				  facility services (refer to OAC
				  317:30-5-95
				  through
				  317:30-5-97);
(10) Applied behavior analysis (ABA) (refer
				  to OAC 317:30-5-310 through 317:30-5-316); and
(11) Diabetes self-management education and
				  support (DSMES) (refer to OAC 317:30-5-1080 through 317:30-5-1084) .
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1091 - Definition of I/T/U services

Current through Vol. 41, No. 20, July 1, 2024
(a) As
				  described in
				  42 CFR
				  136.11(a), the I/T/U
				  services may include hospital and medical care, dental care, public health
				  nursing, preventive care (including immunizations).
(b) Further,
				  42 CFR
				  136.11(c) allows that the
				  scope and availability of I/T/U services will depend upon the resources of the
				  facility.
(c) I/T/U services may
				  be covered when furnished to a patient at the clinic or other location,
				  including a mobile clinic, or the patient's place of residence. Provider
				  contracts must meet the provider participation requirements found at OAC
				  317:30-5-1096.
(d) I/T/U outpatient encounters
				  include but are not limited to:
(1)
				  Physicians' services and supplies incidental to a physician's services;
(2) Within limitations as to the
				  specific services furnished, a doctor of dentistry or oral surgery, a doctor of
				  optometry, or a doctor of podiatry [Refer to Section 1861(r) of the Act for
				  specific limitations];
(3)
				  Services of advanced practice nurses (APNs), physician assistants (PAs),
				  certified nurse midwives (CNMs), or specialized advanced practice nurse
				  practitioners;
(4) Services and
				  supplies incidental to the services of APNs and PAs (including services
				  furnished by certified nurse midwives);
(5) Public health nursing services, within
				  the scope of their licensure, include but are not limited to services in the
				  following areas:
(A) Phlebotomy;
(B) Wound care;
(C) Public health education;
(D) Administration of immunizations;
(E) Administration of medication;
(F) Child health screenings
				  meeting EPSDT criteria;
(G)
				  Smoking and Tobacco Use Cessation Counseling;
(H) Prenatal, newborn and postpartum
				  assessments, including case management services for first time mothers; and
(I) General health assessments and
				  management of conditions such as tuberculosis, diabetes and hypertension.
(6) Visiting nurse
				  services to the homebound;
(7)
				  Behavioral health professional services and services and supplies incidental to
				  the services of LBHPs; and
(8)
				  Dental services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1092 - Services and supplies incidental to I/T/U outpatient encounters

Current through Vol. 41, No. 20, July 1, 2024
Services and supplies incidental to the service of a
					 physician, physician assistant, advanced practice nurse, clinical psychologist,
					 or clinical social worker may be covered if the service or supply is:
(1) of a type commonly furnished in
				  physicians' offices;
(2) of a type
				  commonly rendered either without charge or included in the I/T/U's
				  bill;
(3) furnished as an
				  incidental, although integral, part of professional services furnished by a
				  physician, nurse practitioner, physician assistant, nurse midwife, or
				  specialized nurse practitioner;
(4)
				  furnished under the direct, personal supervision of a nurse practitioner,
				  physician assistant, nurse midwife, specialized nurse practitioner or a
				  physician; and
(5) in the case of a
				  service, furnished by a member of the I/T/U's health care staff who is an
				  employee of the clinic.
Added at 23 Ok Reg
					 2575, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1093 - I/T/U visiting nurses services

Current through Vol. 41, No. 20, July 1, 2024
(a) Visiting nurse services may be covered
				  if:
(1) The services are rendered to a
				  homebound individual who is permanently or temporarily confined to his or her
				  place of residence because of a medical or health condition. The individual may
				  be considered homebound if he or she leaves the place of residence
				  infrequently. For this purpose, place of residence does not include a hospital
				  or long term care facility; and
(2) The services are furnished by a
				  registered nurse, licensed practical nurse, or licensed vocational nurse who is
				  employed by, and receives compensation for the services from the I/T/U; and
(3) The services are furnished
				  under a written plan of treatment that is:
(A) established and reviewed at least every
				  60 days by a supervising physician of the I/T/U or established by a nurse
				  practitioner, physician assistant, nurse midwife, or specialized nurse
				  practitioner and reviewed at least every 60 days by a supervising physician;
				  and
(B) signed by the nurse
				  practitioner, physician assistant, nurse midwife, specialized nurse
				  practitioner, or the supervising physician of the clinic.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1094 - Behavioral health services provided at I/T/Us

Current through Vol. 41, No. 20, July 1, 2024
(a)
Inpatient
				  behavioral health.
Services are covered when provided in accordance with
				  a documented individualized service plan developed to treat the identified
				  behavioral health needs.
(1) Inpatient
				  psychiatric service providers must meet the requirements and applicable
				  limitations, restrictions, or prior authorization requirements set forth in
				  Oklahoma Administrative Code (OAC)
				  317:30-5-95 through
				  317:30-5-97.
(2) The provision of inpatient psychiatric
				  services by Indian Health Services (IHS) facilities are reimbursed at the OMB
				  inpatient encounter rate. Inpatient psychiatric services provided by non-IHS
				  facilities are reimbursed at the established per diem or DRG
				  rate.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1095 - I/T/U services not compensable under outpatient encounters

Current through Vol. 41, No. 20, July 1, 2024
I/T/U services that are not compensable under outpatient
					 encounters include:
(1) group or mass
				  information programs, health education classes, or group education activities,
				  including media productions and publications;
(2) vaccines covered by the Vaccines for
				  Children program [refer to Oklahoma Administrative Code
				  317:30-5-14(a)(1)
				  ];
(3) group or sports physicals
				  and medical reports;
(4) drug
				  samples or other prescription drugs provided to the clinic free of charge;
(5) administrative medical
				  examinations and report services; and
(6) gauze, band-aids, or other disposable
				  products used during an office visit; and
(7) billing global obstetrical care when
				  performing a cesarean or vaginal delivery only.
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1096 - Off-site services

Current through Vol. 41, No. 20, July 1, 2024
I/T/U covered services provided off-site or outside of the
					 I/T/U setting, including but not limited to hospice services, mobile clinics,
					 or places of residence, are compensable at the OMB rate when billed by an I/T/U
					 that has been designated as a Federally Qualified Health Center. The I/T/U must
					 meet provider participation requirements listed in OAC
					 317:30-5-1088. I/T/U off-site
					 services may be covered if the services rendered were within the provider's
					 scope of practice and are of the same integrity of services rendered at the
					 I/T/U facility.
Added at 23 Ok Reg
					 2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1097 - Billable I/T/U encounters

Current through Vol. 41, No. 20, July 1, 2024
I/T/U encounters that are billed to the OHCA must meet the
					 definition listed in OAC
					 317:30-5-1099
					 and are limited to medically necessary State Plan services covered by OHCA.
					 These services include ambulatory services included in the State Plan under
					 Title XIX or Title XXI of the Social Security Act.
Added at 23 Ok Reg
					 2575, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1098 - Indian Health Services, Tribal Programs, and Urban Indian clinics (I/T/Us) outpatient encounters

Current through Vol. 41, No. 20, July 1, 2024
(a) I/T/U
				  outpatient encounters that are billed to the OHCA must meet the definition in
				  this Section and are limited to services covered by the OHCA. These services
				  include health services included in the State Plan under Title XIX or Title XXI
				  of the Social Security Act.
(1) An I/T/U
				  encounter means a face to face, a telehealth contact, or an audio-only
				  telecommunications contact between a health care professional and an Indian
				  Health Services (IHS) eligible SoonerCare member for the provision of medically
				  necessary Title XIX or Title XXI covered services through an IHS or Tribal 638
				  facility or an urban Indian clinic within a twenty-four (24) period ending at
				  midnight, as documented in the patient's record.
(2) An I/T/U outpatient encounter means
				  outpatient services that may be covered when furnished to a patient by a
				  contracted SoonerCare provider employed by the I/T/U facility and rendered at
				  the I/T/U facility or other location, including the patient's place of
				  residence.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1098 - I/T/U outpatient encounters

Current through Vol. 41, No. 20, July 1, 2024
(a) I/T/U
				  outpatient encounters that are billed to the OHCA must meet the definition in
				  this Section and are limited to services covered by the OHCA. These services
				  include health services included in the State Plan under Title XIX or Title XXI
				  of the Social Security Act.
(1) An I/T/U
				  encounter means a face to face or telehealth contact between a health care
				  professional and an IHS eligible SoonerCare member for the provision of
				  medically necessary Title XIX or Title XXI covered services through an IHS or
				  Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at
				  midnight, as documented in the patient's record.
(2) An I/T/U outpatient encounter means
				  outpatient services that may be covered when furnished to a patient by a
				  contracted SoonerCare provider employed by the I/T/U facility and rendered at
				  the I/T/U facility or other location, including the patient's place of
				  residence.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1099 - I/T/U service limitations and requirements

Current through Vol. 41, No. 20, July 1, 2024
Service limitations governing the provision of all
					 Oklahoma SoonerCare services will apply pursuant to Chapter 30 of the OHCA
					 rules. In addition, the following limitations and requirements apply to
					 services provided by I/T/U facilities:
(1)
Multiple encounters.
An
				  I/T/U facility may bill for more than one encounter per twenty-four (24) hour
				  period under certain conditions.
(2)
Behavioral Health services.
Behavioral Health Services are limited to those services furnished to members
				  at or on behalf of the I/T/U facility.
(3)
Laboratory procedures.
Laboratory procedures performed by an I/T/U outpatient facility (not an
				  independently certified enrolled laboratory) on the same date of service are
				  considered part of the health care practitioner's service and are included in
				  the I/T/U encounter.
(4)
Obstetrical services.
For OB services provided to a member before,
				  during, and/or after the same pregnancy, ITUs may not bill for individual
				  encounters and the package/bundled rate. Providers may only either:
(A) bill for antepartum visits, postpartum
				  visits, and/or a cesarean or vaginal delivery as individual encounter; or
(B) bill the packaged/bundled rate
				  for total care obstetrics, (which includes antepartum and postpartum visits and
				  delivery). Refer to Oklahoma Administrative Code
				  317:30-5-22 for
				  more detailed obstetrical care policy.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 110 - INDIAN HEALTH SERVICES, TRIBAL PROGRAMS, AND URBAN INDIAN CLINICS (I/T/Us) › Section 317:30-5-1100 - Inpatient care provided by IHS facilities

Current through Vol. 41, No. 20, July 1, 2024
Inpatient practitioner services are separately contracted
					 and paid at a fee-for-service rate. Each individual inpatient practitioner must
					 be contracted with SoonerCare and attached to a SoonerCare contracted medical
					 group. The Inpatient hospital per diem rate for inpatient medical care provided
					 by IHS facilities is published annually in the Federal Register or Federal
					 Register Notices. In order to receive the inpatient hospital per diem rate, the
					 IHS or Tribal 638 facility must:
(1)
				  be contracted as a provider with the Oklahoma Health Care Authority; and
(2) appear on the IHS maintained
				  listing of IHS-operated and Indian health care facilities operating under a 638
				  agreement. It is the sole responsibility of the facility to petition IHS for
				  placement on this list.
Added at 25 Ok Reg
					 2698, eff 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1150 - General

Current through Vol. 41, No. 20, July 1, 2024
Public Health Clinic services consist of primary and
					 preventive health care, related diagnostic services, and/or dental services.
					 County health departments (CHDs) and City-County Health Departments (CCHDs) may
					 participate as providers in the SoonerCare program as Public Health Clinics.
					 The Statutory basis for their participation is pursuant to
					 42
					 CFR 431.615 (Relations with State Health and
					 Vocational Rehabilitation Agencies and Title V Grantees), thereby implementing
					 Sec. 1902(a)(11) and (22)(C) of the Social Security Act. The CHD Clinics are
					 administered by the Oklahoma State Department of Health (OSDH) for the purpose
					 of providing public health services.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1151 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
To be eligible for reimbursement, a CHD or the OSDH (on
					 behalf of the CHDs) or CCHD, must complete a provider contract with the
					 Oklahoma Health Care Authority (OHCA). The CHD or CCHD clinic must have a
					 licensed physician on staff or physician supervising the services. The
					 supervising physician must be available at all times in person or by direct
					 telecommunication for advice and assistance on patient referrals or
					 emergencies. Clinic services must be provided in accordance with
					 42 CFR
					 440.90.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1152 - Provider participation requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) OSDH and or/ CHD or CCHD must employ or
				  contract the services of professional staff that are authorized within their
				  scope of practice under state law to provide the services for which claims are
				  submitted to the OHCA.
(b) The OSDH
				  and CCHDs are required to submit a list of names of all practitioners who are
				  working within the CHD and not individually enrolled with the OHCA when
				  requested by the OHCA or it's designated agent.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1153 - Physician

Current through Vol. 41, No. 20, July 1, 2024
Physicians who perform services in Oklahoma, but who are
					 not licensed in Oklahoma may provide services for the CHD/CCHD if they are
					 commissioned medical officers of the Public Health Service or Armed Services of
					 the United States, on active duty, and acting within the scope of their Public
					 Health Service or military responsibilities.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1154 - County health department (CHD)and city-county health department (CCHD) services/limitations

Current through Vol. 41, No. 20, July 1, 2024
CHD/CCHD service limitations are:
(1) Child-guidance services (refer to
				  Oklahoma Administrative Code (OAC)317:30-5-1023
				  ).
(2) Dental services (refer to
				  OAC
				  317:30-3-65.4(7)
				  for specific coverage).
(3) Early
				  and Periodic Screening, Diagnostic and Treatment (EPSDT) services, including
				  blood lead testing and follow-up services (refer to OAC
				  317:30-3-65
				  through
				  317:30-3-65.12
				  for specific coverage).
(4)
				  Environmental investigations.
(5)
				  Family planning and Sooner Plan family planning services (refer to OAC
				  317:30-5-12 for
				  specific coverage guidelines).
(6)
				  Immunizations (adult and child).
(7) Blood lead testing (refer to OAC
				  317:30-3-65.4
				  for specific coverage).
(8)
				  Newborn hearing screening.
(9)
				  Newborn metabolic screening.
(10)
				  Maternity services (refer to OAC
				  317:30-5-22 for
				  specific coverage).
(11) Public
				  health nursing services.
(12)
				  Tuberculosis case management and directly observed therapy.
(13) Laboratory services.
(14) Targeted case management.
Added at 24 Ok Reg
					 2070, eff 6-25-07; Amended at 29 Ok Reg 1085, eff
					 6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1155 - Immunizations

Current through Vol. 41, No. 20, July 1, 2024
(a) Immunizations
				  are administered in accordance with Centers for Disease Control, Advisory
				  Committee on Immunization Practices.
(b) The Vaccines for Children (VFC) program
				  offers free vaccines to qualified health care providers for children 18 years
				  of age and under who are Soonercare members, American Indian or Alaska Native,
				  uninsured, or under insured. The Oklahoma State Department of Health
				  administers this program.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1156 - Environmental lead investigations

Current through Vol. 41, No. 20, July 1, 2024
Environmental inspections are provided through the Oklahoma
					 State Department of Health (OSDH) upon notification from laboratories or
					 providers and reimbursed through the Oklahoma SoonerCare program. The OCLPPP
					 schedules an environmental inspection to identify the source of the lead for
					 children who have a persistent blood lead level 15 ug/dL or greater. After the
					 results of the environmental inspection have been received, the OHCA and OCLPPP
					 continue case management activities until two consecutive blood lead
					 measurements equal to or below 10 ug/dL have been achieved. A qualified
					 investigator must be certified, accredited or granted approval by the Oklahoma
					 Department of Environmental Quality to perform environmental lead
					 testing.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1157 - Newborn screening

Current through Vol. 41, No. 20, July 1, 2024
(a) The newborn
				  hearing screening is for the purpose of testing all newborns for hearing
				  impairments to alleviate the adverse effects of hearing loss or speech and
				  language development. The screening is a test or battery of tests administered
				  to determine the need for an in-depth hearing diagnostic evaluation. Payment
				  for the initial screening is included in the inpatient facility payment.
				  Follow-up screening is covered if the child has not been seen by his/her
				  PCP/CM.
(b) The newborn metabolic
				  screening is for the purpose of testing all newborns born in Oklahoma for
				  disorders as determined by the OSDH Board of Health. Short-term and long-term
				  follow-up services are provided in conjunction with the laboratory
				  testing.
Added at 24 Ok Reg
					 2070, eff 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1158 - Public health nursing services

Current through Vol. 41, No. 20, July 1, 2024
(a) Public health nursing services must be
				  performed at a main clinic site, satellite clinic or mobile clinic site that is
				  open to the public, or a member's home.
(b) Clinic visits may include but are not
				  limited to services in the following areas:
(1) health promotion and
				  counseling;
(2) medication
				  management;
(3) nursing assessment,
				  treatment and diagnostic testing;
(4) home visits;
(5) nursing treatments;
(6) immunizations;
(7) administration of injectable
				  medications;
(8) medication
				  management and the direct observation of the intake of prescribed drugs to
				  treat tuberculosis (TB); and
(9)
				  case management for TB, first time mothers and their infant children, and high
				  risk pregnant women.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1159 - Tuberculosis

Current through Vol. 41, No. 20, July 1, 2024
The purpose of the Tuberculosis program is to identify and
					 treat clients with tuberculosis, insure appropriate measures are taken to
					 prevent the occurrence and transmission of tuberculosis, analyze tuberculosis
					 related data for program planning and evaluation, and ultimately eliminate
					 tuberculosis in Oklahoma. Payment is made for tuberculosis clinic services
					 pursuant to (1) - (7) of this Section.
(1)
Nursing visit - regular with
				  disease.
Nursing visit - regular with disease requires an initial
				  intensive interview by Health Department personnel for gathering clinical and
				  epidemiologic data and administration of a tuberculosis skin test.
(A) The nursing visit in this paragraph
				  includes:
(i) one x-ray every two
				  months;
(ii) a monthly blood
				  test;
(iii) one series (3 samples)
				  of sputum tests every two months;
(iv) monitoring of side effects;
				  and
(v) provision of
				  medication.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1160 - Public health nursing services for first time mothers and their infants/children (Children's First program)

Current through Vol. 41, No. 20, July 1, 2024
(a) The purpose of the Children's First
				  program is to make home visits to low income, first time parents teaching them
				  about pregnancy, nutrition, fetal development and how to care for themselves
				  and their baby after delivery. A first time mother is:
(1) a woman who is expecting her first live
				  birth, has never parented and plans on parenting this child;
(2) a woman who is expecting her first live
				  birth, has never parented and is contemplating placing the child for
				  adoption;
(3) a woman who has been
				  pregnant, but has not delivered a child due to abortion or
				  miscarriage;
(4) a woman who is
				  expecting her first live birth, but has parented stepchildren or younger
				  siblings;
(5) a woman who has
				  delivered a child, but her parental rights were legally terminated within the
				  first few months of that child's life; or
(6) a woman who has delivered a child, but
				  the child died within the first few months of life.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 112 - PUBLIC HEALTH CLINIC SERVICES › Section 317:30-5-1161 - Targeted case management

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Case management is a set of interrelated activities under which responsibility
				  for locating, coordinating and monitoring appropriate services for an
				  individual rests with a specific person within the case management agency.
				  Services under case management are not comparable in amount duration and
				  scope.
(b) Case management is
				  designed to assist a individual in gaining access to needed medical, social,
				  educational and other services essential to meeting basic human needs, and is
				  not restrictive in nature.
(c)
				  Major components of the services include working with the individual in the use
				  of basic community resources, referral, linkage and advocacy.
(d) In order to ensure that case management
				  services are not duplicated by other staff, case management activities will be
				  provided in accordance with a comprehensive individualized treatment/service
				  plan. The development of this plan includes clinical staff participation, thus
				  ensuring that staff knows a client has a case manager.
(e) Case management services for first time
				  mothers must provide necessary coordination with providers of non-medical
				  services, such as nutrition, psycho social or health education programs, when
				  services provided by these entities are needed. The case manager coordinates
				  these services with needed medical services. The purpose of case management
				  services for first time mothers and their infants/children is to:
(1) assist first time mothers and their
				  infants/children in gaining access to needed medical, social, educational and
				  other services;
(2) encourage the
				  use of appropriate medical providers; and
(3) discourage over utilization or
				  duplication of services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 113 - LIVING CHOICE PROGRAM › Section 317:30-5-1200 - Benefits for members age 65 or older with disabilities or long-term illnesses

Current through Vol. 41, No. 20, July 1, 2024
(a) Living
				  Choice program participants age 65 or older with disabilities or long-term
				  illnesses may receive a range of necessary medical and home and community based
				  services for one year after moving from an institutional setting. The one year
				  period begins the day the member occupies a qualified residence in the
				  community. Once this transition period is complete, the member receives
				  services through one of the Opportunities for Living Life home and community
				  based services waivers.
(b)
				  Services must be billed using the appropriate HCPCS or CPT codes and must be
				  medically necessary.
(c) All
				  services must be necessary for the individual to live in the community, require
				  prior authorization, and must be documented in the individual transition plan.
				  The number of units of services the member is eligible to receive is limited to
				  the amounts approved in the transition plan.
(d) Services that may be provided through the
				  Living Choice program for older persons with disabilities or long-term
				  illnesses are listed in paragraphs (1) through (26) of this subsection:
(1) case management;
(2) respite care;
(3) adult day health care;
(4) environmental modifications;
(5) specialized medical equipment and
				  supplies;
(6) therapy services
				  including physical, occupational, speech and respiratory;
(7) advanced supportive/restorative
				  assistance;
(8) skilled
				  nursing;
(9) extended duty
				  nursing;
(10) home delivered
				  meals;
(11) hospice care;
(12) medically necessary prescription
				  drugs;
(13) personal care as
				  described in Part 95 of this Chapter;
(14) Personal Emergency Response System
				  (PERS);
(15)
				  self-direction;
(16) transition
				  coordination;
(17) community
				  transition services as described in OAC
				  317:30-5-1205;
(18) dental services (up to $1,000 per person
				  annually);
(19) nutrition
				  evaluation and education services;
(20) agency companion services;
(21) pharmacological evaluations;
(22) vision services including eye
				  examinations and eyeglasses;
(23)
				  non-emergency transportation;
(24)
				  family training services;
(25)
				  assisted living services; and
(26)
				  SoonerCare compensable medical services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 113 - LIVING CHOICE PROGRAM › Section 317:30-5-1201 - Benefits for members with intellectual disabilities

Current through Vol. 41, No. 20, July 1, 2024
(a) Living Choice program participants with
				  intellectual disabilities may receive a range of necessary medical and home and
				  community based services for one year after moving from the institution. The
				  one year period begins the day the member occupies a qualified residence in the
				  community. Once this transition period is complete, the member receives
				  services through the Community waiver.
(b) Services must be billed using the
				  appropriate HCPCS or CPT codes and must be medically necessary.
(c) All services must be necessary for the
				  individual to live in the community, require prior authorization, and must be
				  documented in the individual transition plan. The number of units of services
				  the member is eligible to receive is limited to the amounts approved in the
				  transition plan. The transition plan may be amended as the member's needs
				  change.
(d) Services that may be
				  provided to members with intellectual disabilities are listed in paragraphs (1)
				  through (28) of this subsection:
(1)
				  assistive technology;
(2) adult day
				  health care;
(3) architectural
				  modifications;
(4) audiology
				  evaluation and treatment;
(5)
				  community transition;
(6) daily
				  living support;
(7) dental
				  services;
(8) family
				  counseling;
(9) family
				  training;
(10) group
				  home;
(11) respite care;
(12) homemaker services;
(13) habilitation training
				  services;
(14) home health
				  care;
(15) intensive personal
				  support;
(16) extended duty
				  nursing;
(17) skilled
				  nursing;
(18) nutrition
				  services;
(19) therapy services
				  including physical, occupational, and speech;
(20) psychiatry services;
(21) psychological services;
(22) agency companion services;
(23) non-emergency transportation;
(24) pre-vocational services;
(25) supported employment services;
(26) specialized foster care;
(27) specialized medical equipment and
				  supplies; and
(28) SoonerCare
				  compensable medical services.