Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-14 - Freedom of choice

Current through Vol. 41, No. 20, July 1, 2024
(a)
Any
				  Qualified provider.
The Oklahoma Health Care Authority (OHCA) assures
				  that any individual eligible for SoonerCare, may obtain services from any
				  institution, agency, pharmacy, person, or organization that is contracted with
				  OHCA and qualified to perform the services.
(b)
Member lock-in.
SoonerCare
				  members who have demonstrated utilization above the statistical norm, during a
				  6-month period, may be "locked-in" to a prescriber and/or one pharmacy for
				  medications classified as controlled dangerous substances in accordance with
				  42 CFR
				  431.54.
(1)
				  Over-utilization patterns by SoonerCare members may be identified either by
				  referral or by OHCA automated computer systems. SoonerCare records, for a
				  6-month period, of those identified members are then reviewed. Medical and
				  pharmacy claim histories are reviewed by OHCA pharmacy consultants to determine
				  if the member has unreasonably utilized SoonerCare provider and/or prescription
				  services.
(2) If it is determined
				  that SoonerCare has been over-utilized, the member may be notified, by letter,
				  of the need to select a prescriber and/or pharmacy and of their opportunity for
				  a fair hearing in accordance with OAC
				  317:2-1-2. If the member
				  does not select a prescriber or pharmacy, one will be selected for the member.
(3) The prescriber and/or pharmacy
				  of choice, unless the aforementioned providers have been identified as having
				  problems with over-utilization, are notified by letter and given an opportunity
				  to accept or decline to be the member's prescriber and/or pharmacy.
(4) When the provider accepts, a confirmation
				  letter is sent to both member and provider showing the effective date of the
				  arrangement.
(5) After the lock-in
				  arrangement is made, the provider may file claims for services provided in
				  accordance with OHCA guidelines.
(6) Locked-in members may obtain emergency
				  services from an emergency room facility for an emergency medical condition or
				  as part of an inpatient admission.
(7) If a claim for a controlled dangerous
				  substance is filed by another pharmacy, the claim will be denied.
(8) A member placed in the lock-in program
				  will remain in lock-in status for a minimum of 24 months. While in lock-in
				  status, the member's usage shall be monitored periodically and shall be
				  reviewed at the end of 24 months.
(9) Following a review, OHCA may elect to
				  continue lock-in for an additional period of up to 24 months, remove the member
				  from lock-in based upon medical necessity, or remove the member based upon
				  program compliance. The member will be provided written notice of OHCA's
				  decision and afforded an opportunity to appeal. OHCA retains the right at any
				  time to impose sanctions in an appropriate case pursuant to OAC
				  317:35-13-7
				  or to take other appropriate action for abusive conduct.
(10) The member in the lock-in program may
				  make a request to change providers after the initial three months; when the
				  member moves to a different city or if the member feels irreconcilable
				  differences will prevent necessary medical care. Change of providers based on
				  irreconcilable differences must be approved by OHCA staff or contractor.
(11) OHCA may make a provider
				  change when the provider makes a request for change or may initiate a change
				  anytime it is determined necessary to meet program goals.