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 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.6 - General documentation requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) Section 1833(e) of the Social Security
				  Act precludes payment to any provider of service unless "there has been
				  furnished such information as may be necessary in order to determine the
				  amounts due such provider" [42 United States Code (U.S.C.) Section 1395l(e)].
				  The member's medical records will reflect the need for the care provided. The
				  member's medical records should include the physician's office records,
				  hospital records, nursing home records, home health agency records, records
				  from other health care professionals and test reports. This documentation must
				  be provided for prior authorization requests and available to the Oklahoma
				  Health Care Authority (OHCA) or its designated agent upon request.
(b) Payment is made for durable medical
				  equipment as set forth in this section when a face-to-face encounter has
				  occurred in accordance with provisions of
				  42 Code of Federal Regulations (C.F.R.) §
											440.70 and Oklahoma Administrative Code (OAC)
				  317:30-5-211.1.
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.7 - Free choice

Current through Vol. 41, No. 20, July 1, 2024
A member has the choice of which provider will fill the
					 prescription or order for a DMEPOS. . All providers must inform the member they
					 have a choice of provider when filling or ordering DMEPOS.
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.8 - Coverage [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Revoked at
					 27 Ok Reg 453, eff 12-3-09 (emergency); Revoked at 27 Ok Reg 942, eff
					 5-13-10
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 317:30-5-211.9 - Adaptive equipment [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.10 - Medical supplies, equipment, and appliances

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical
				  supplies, equipment, and appliances.
See the definition for medical
				  supplies, equipment, and appliances at Oklahoma Administrative Code (OAC)
				  317:30-5-211.1.
(b)
Certificate of medical necessity
				  (CMN).
Certain items of medical supplies, equipment, and appliances
				  require a CMN/OHCA CMN which should be submitted with the request for prior
				  authorization. These items include, but are not limited to:
(1) Enteral and parenteral nutrition;
				  and
(2) Support
				  surfaces.
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 317:30-5-211.11 - Oxygen and oxygen equipment

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical
				  necessity.
Oxygen and oxygen supplies are covered when medically
				  necessary. Medical necessity is determined from results of arterial blood gas
				  analysis (ABG) or pulse oximetry (SaO2) tests. ABG data are not required for
				  children, but may be used if otherwise available. The test results to document
				  Medical Necessity must be within thirty (30) days of the date of the qualified
				  medical practitioner's order. Prior authorization is required after the initial
				  three (3) months of billing whether qualifying tests were done at rest, during
				  sleep, or during exercise. Appropriate documentation of ABG or SaO2 data from
				  the member's chart should be attached to the prior authorization request (PAR).
(1) The ABG or oximetry test used to
				  determine medical necessity must be performed by a medical professional
				  qualified to conduct such testing. The test may not be performed or paid for by
				  a DMEPOS supplier, or a related corporation. A referring qualified medical
				  practitioner may perform the test in his/her office as part of routine member
				  care.
(2) In addition to ABG data,
				  the following three (3) tests are acceptable for determining medical necessity
				  for oxygen prescription:
(A) At rest and
				  awake "spot oximetry."
(B) During
				  sleep:
(i) Overnight Sleep Oximetry done
				  inpatient or at home.
(ii)
				  Polysomnogram, which may be used only if medically necessary for concurrent
				  evaluation of another condition while in a chronic stable
				  state.
(C) During
				  exercise with all three (3) of the following performed in the same testing
				  session.
(i) At rest, off oxygen showing a
				  non-qualifying result.
(ii) During
				  exercise, off oxygen showing a qualifying event.
(iii) During exercise, on oxygen showing
				  improvement over test (C) ii above.
(3) Certification criteria:
(A) All qualifying testing must meet the
				  following criteria:
(B) Adults.
				  Initial requests for oxygen must include ABG or resting oximetry results. At
				  rest and on room air, the arterial blood saturation (SaO2) cannot exceed
				  eighty-nine percent (89%) or the pO2 cannot exceed 59mm Hg.
(C) Children. Members twenty (20) years of
				  age or less must meet the following requirements:
(i) birth through three (3) years, SaO2 equal
				  to or less than ninety-four percent (94%); or
(ii) ages four (4) and above, SaO2 level
				  equal to or less than ninety percent (90%).
(iii) Requests from the qualified medical
				  practitioner for oxygen for children who do not meet these requirements should
				  include documentation of the medical necessity based on the child's clinical
				  condition. These requests are considered on a case-by-case
				  basis.
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 317:30-5-211.12 - Oxygen rental

Current through Vol. 41, No. 20, July 1, 2024
A monthly rental payment is made for rental of liquid
					 oxygen systems, gaseous oxygen systems and oxygen concentrators. The rental
					 payment for a stationary system includes all contents and supplies, such as,
					 regulators, tubing, masks, etc., that are medically necessary. An additional
					 monthly payment may be made for a portable liquid or gaseous oxygen system
					 based on medical necessity.
(1)
				  Stationary oxygen systems and portable oxygen systems are covered items for
				  members residing in their home and in any setting in which normal life
				  activities take place except for a hospital, long-term care facility,
				  intermediate care facility for individuals with intellectual disabilities, or
				  any other setting in which payment is or could be made under Medicaid for
				  inpatient services that include room and board.
(2) For members who meet medical necessity
				  criteria, SoonerCare covers portable liquid or gaseous oxygen systems. Payment
				  for both oxygen contents used with stationary oxygen equipment and oxygen
				  contents used with portable oxygen equipment is included in the monthly
				  payments for oxygen and oxygen equipment. The need for a portable oxygen system
				  must be stated on the CMN. A portable system that is used as a backup system
				  only is not a covered item.
(3)
				  When four(4) or more liters of oxygen are medically necessary, an additional
				  payment will be paid up to one hundred and fifty percent (150%) of the
				  allowable for a stationary system when billed with the appropriate
				  modifier.
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 628, eff 14-13-10 (emergency); Amended at 27 Ok Reg 1451, eff
					 6-11-10
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 317:30-5-211.13 - Orthotics and prosthetics

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Coverage of prosthetics for non-expansion adults is limited to (1) home
				  dialysis equipment and supplies, (2) nerve stimulators, (3) external breast
				  prosthesis and support accessories, and (4) implantable devices inserted during
				  the course of a surgical procedure. Prosthetics prescribed by an appropriate
				  qualified provider and as specified in this section are covered items for
				  non-expansion adults. There is no coverage of orthotics for non-expansion
				  adults.
(1)
Home dialysis.
Equipment and supplies are covered items for members receiving home dialysis
				  treatments only.
(2)
Nerve
				  stimulators.
Payment is made for transcutaneous nerve stimulators,
				  implanted peripheral nerve stimulators, and neuromuscular
				  stimulators.
(3)
Breast
				  prosthesis, bras, and prosthetic garments.
(A) Payment is limited to:
(i) One (1) prosthetic garment with
				  mastectomy form every twelve (12) months for use in the postoperative period
				  prior to a permanent breast prosthesis or as an alternative to a mastectomy bra
				  and breast prosthesis;
(ii) Two (2)
				  mastectomy bras per year; and
(iii)
				  One (1) silicone or equal breast prosthetic per side every twenty-four (24)
				  months; or
(iv) One (1) foam
				  prosthetic per side every six(6) months.
(B) Payment will not be made for both a
				  silicone and a foam prosthetic in the same twelve (12) month period.
(C) Breast prostheses, bras, and prosthetic
				  garments must be purchased from a Board Certified Mastectomy Fitter.
(D) A breast prosthesis can be replaced if:
(i) Lost;
(ii) Irreparable damaged (other than ordinary
				  wear and tear); or
(iii) The
				  member's medical condition necessitates a different type of item and the
				  physician provides a new prescription explaining the need for a different type
				  of prosthesis.
(E)
				  External breast prostheses are not covered after breast reconstruction is
				  performed except in instances where a woman with breast cancer receives
				  reconstructive surgery following a mastectomy, but the breast implant fails or
				  ruptures and circumstances are such that an implant replacement is not
				  recommended by the surgeon and/or desired by the member.
(4)
Prosthetic devices inserted during
				  surgery.
Separate payment is made for prosthetic devices inserted during
				  the course of surgery when the prosthetic devices are not integral to the
				  procedure and are not included in the reimbursement for the procedure itself.
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 317:30-5-211.14 - Nutritional support

Current through Vol. 41, No. 20, July 1, 2024
(a)
Enteral
				  nutrition.
Enteral nutrition administered only via gravity, syringe, or
				  pump is covered for children and adults at home. Refer to pharmacy policy
				  related to coverage of food supplements at Oklahoma Administrative Code (OAC)
				  317:30-5-72.1(2)(C).
				  For enteral nutrition authorization guidelines, see OAC
				  317:30-5-211.20.
(b)
Parenteral nutrition.
The member must require intravenous feedings
				  to maintain weight and strength commensurate with the member's overall health
				  status. Adequate nutrition must not be possible by dietary adjustment and/or
				  oral supplements.
(1) The member must have a
				  permanent impairment. Permanence does not require a determination that there is
				  no possibility that the member's condition may improve sometime in the future.
				  If the judgment of the attending physician, substantiated in the medical
				  record, is that the condition is of long and indefinite duration (ordinarily at
				  least three(3) months), the test of permanence is met. Parenteral nutrition
				  will be denied as a non-covered service in situations involving temporary
				  impairments.
(2) The member must
				  have a condition involving the small intestine, exocrine glands, or other
				  conditions that significantly impair the absorption of nutrients. Coverage is
				  also provided for a disease of the stomach and/or intestine that is a motility
				  disorder and impairs the ability of nutrients to be transported through the GI
				  system, and other conditions as deemed medically necessary. There must be
				  objective medical evidence supporting the clinical diagnosis.
(3) Re-certification of parenteral nutrition
				  will be required as medically necessary and determined by the Oklahoma Health
				  Care Authority (OHCA) medical staff.
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 317:30-5-211.15 - Medical Supplies

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) provides
					 coverage for medically necessary supplies that are prescribed by the
					 appropriate medical provider and meet the member's specific needs. Medical
					 supplies include, but are not limited to, IV therapy supplies, diabetic
					 supplies, catheters, colostomy and urostomy supplies, and incontinence
					 supplies.
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 628, eff 14-13-10 (emergency); Amended at 27 Ok Reg 1451, eff
					 6-11-10
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 317:30-5-211.16 - Coverage for long-term care facility residents

Current through Vol. 41, No. 20, July 1, 2024
For residents in a long-term care facility, medical
					 supplies, equipment and appliances are included in the facility's per diem
					 rate. Orthotics and prosthetics are paid separately from the per diem rate in
					 accordance with the Oklahoma Medicaid State Plan. Refer to Oklahoma
					 Administrative Code (OAC)
					 317:30-5-211.13
					 for orthotics and prosthetics coverage.
Added at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.17 - Wheelchairs

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following words and terms, when used in this
				  Section, have the following meaning, unless the context clearly indicates
				  otherwise.
(1)
"Assistive technology
				  professional"
or
"ATP"
means a for-service provider who is
				  involved in analysis of the needs and training of a consumer in the use of a
				  particular assistive technology device or is involved in the sale and service
				  of rehabilitation equipment or commercially available assistive technology
				  products and devices. All ATPs are required to be credentialed by
				  Rehabilitation Engineering and Assistive Technology Society of North America
				  (RESNA).
(2)
"Custom seating
				  system"
means a wheelchair seating system which is individually made for
				  a member using a plaster model of the member, a computer-generated model of the
				  member (e.g., CAD-CAM technology), or the detailed measurements of the member
				  to create either:
(A) A molded, contoured, or
				  carved (foam or other suitable material) custom-fabricated seating system that
				  is incorporated into the wheelchair base; or
(B) A custom seating system made from
				  multiple pre-fabricated components or a combination of custom fabricated
				  materials and pre-fabricated components which have been configured and attached
				  to the wheelchair base or incorporated into a wheelchair seat and/or back in a
				  manner that the wheelchair could not be easily re-adapted for use by another
				  individual.
(3)
"Specialty evaluation"
means the determination and documentation
				  of the consumer's pathology, history and prognosis, and the physiological,
				  functional, and environmental factors that impact the selection of an
				  appropriate wheeled mobility system.
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 317:30-5-211.18 - Ownership of durable medical equipment

Current through Vol. 41, No. 20, July 1, 2024
Durable medical equipment, prosthetics, orthotics, and
					 supplies (DMEPOS) purchased by SoonerCare are the property of the Oklahoma
					 Health Care Authority (OHCA) to be used for the benefit of the requesting
					 member until it is no longer medically necessary. At such time as the item is
					 no longer medically necessary, OHCA or an OHCA contractor may retrieve the
					 DMEPOS product if it is determined to be administratively and fiscally
					 prudent.
Added at 27 Ok Reg
					 456, eff 12-3-09 (emergency); Added at 27 Ok Reg 946, eff
					 5-13-10
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 317:30-5-211.19 - Quality assurances and safeguards

Current through Vol. 41, No. 20, July 1, 2024
All SoonerCare billed durable medical equipment,
					 prosthetics, orthotics, and supplies (DMEPOS) must have the following quality
					 assurances and safeguards:
(1) All
				  DMEPOS items provided to SoonerCare members must meet manufacturer standards.
				  The equipment must be provided by trained professionals in a manner that is
				  both nationally recognized for safe and effective member care and that meets
				  the member's needs and therapeutic goals, and that the member has received the
				  appropriate education in order to minimize any hazard or safety risks.
(A) DMEPOS suppliers must only provide items
				  that meet applicable state and federal regulations and medical device
				  effectiveness and safety standards.
(B) DMEPOS suppliers must make available the
				  manufacturer copies of the features, warranties, and instructions for each type
				  of item.
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 317:30-5-211.20 - Enteral nutrition

Current through Vol. 41, No. 20, July 1, 2024
(a)
Enteral
				  nutrition.
Enteral nutrition is the delivery of nutrients directly into
				  the stomach, duodenum, or jejunum.
(b)
Medical necessity.
Enteral
				  nutrition supplies must be determined by a provider to be medically necessary
				  and documented in the member's plan of care as medically necessary and used for
				  medical purposes. Requests by qualified providers for enteral nutrition
				  supplies in and of itself shall not constitute medical necessity. The Oklahoma
				  Health Care Authority (OHCA) shall serve as the final authority pertaining to
				  all determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC) 317:30-5-211.2 and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
				  Documentation must include:
(1)
				  Diagnosis;
(2) Certificate of
				  medical necessity (CMN);
(3) Ratio
				  data;
(4) Route;
(5) Caloric intake; and
(6) Prescription.
(7) For full guidelines, please refer to
www.okhca.org/mau
.
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 317:30-5-211.21 - Incontinence supplies

Current through Vol. 41, No. 20, July 1, 2024
(a)
Incontinence supplies and services.
Incontinence supplies and
				  services are those supplies that are used to alleviate or prevent skin
				  breakdown or excoriation associated with incontinence.
(b)
Medical necessity.
Incontinence supplies must be determined by a provider to be medically
				  necessary and documented in the member's plan of care as medically necessary
				  and used for medical purposes. A request by a qualified provider for
				  incontinence supplies in and of itself shall not constitute medical necessity.
				  The Oklahoma Health Care Authority (OHCA) shall serve as the final authority
				  pertaining to all determinations of medical necessity. Refer to Oklahoma
				  Administrative Code (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
				  Documentation must include:
(1) A signed
				  prescription by a provider specifying the requested item;
(2) A documented diagnosis of an underlying
				  chronic medical condition that involves loss of bladder or bowel
				  control;
(3) Documentation must
				  include the height and weight of the member, the type of incontinence
				  (bowel/bladder/combined), and expected length of need;
(4) Requests submitted for
				  underwear/pull-on(s) the member must be ambulatory or in toilet
				  training;
(5) The member may
				  qualify for incontinence supplies for a short period of time when the member
				  has documented full-skin thickness injuries;
(6) When requesting wipes as incontinence
				  supplies, documentation must be submitted specific to the supply being
				  requested. Disposable wipes are only allowed when diapers have been
				  approved;
(7) For full guidelines,
				  please refer to
www.okhca.org/mau
.
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 317:30-5-211.22 - Pulse oximeter

Current through Vol. 41, No. 20, July 1, 2024
(a)
Pulse
				  oximeter.
Pulse oximeter is a device used for measuring blood oxygen
				  levels in a non-invasive manner.
(b)
Medical necessity.
Pulse
				  oximeters must be determined by a provider to be medically necessary and
				  documented in the member's plan of care as medically necessary and used for
				  medical purposes. A request by a qualified provider for pulse oximeters in and
				  of itself shall not constitute medical necessity. The Oklahoma Health Care
				  Authority (OHCA) shall serve as the final authority pertaining to all
				  determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC) 317:30-5-211.2 and OAC
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
				  Documentation must include:
(1) A current
				  oxygen order signed and dated by an OHCA-contracted provider;
(2) Pertinent information relating to the
				  member's underlying diagnosis and condition which results in the need for the
				  oximeter and supplies, including documentation of unstable airway events and
				  documentation of current monitor readings if available; and
(3) Documentation of an available trained
				  caregiver in the home who is able to intervene and address changes in the
				  member's oxygen saturation levels in a medically safe and appropriate
				  manner.
(4) For full guidelines,
				  please refer to
www.okhca.org/mau
.
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 317:30-5-211.23 - Continuous passive motion device for the knee

Current through Vol. 41, No. 20, July 1, 2024
(a)
Continuous passive motion
				  (CPM).
CPM is a postoperative treatment method designed to aid recovery
				  of joint range of motion after joint surgery. CPM provides for early
				  post-operative motion and is considered a substitute for active physical
				  therapy (PT).
(b)
Medical
				  necessity.
CPM must be determined by a provider to be medically
				  necessary and documented in the member's plan of care as medically necessary
				  and used for medical purposes. A request by a qualified provider for CPM in and
				  of itself shall not constitute medical necessity. The Oklahoma Health Care
				  Authority (OHCA) shall serve as the final authority pertaining to all
				  determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(1) A knee
				  CPM device is covered for up to twenty-one (21) days and does not require a
				  prior authorization (PA) for a patient in an early phase of
				  rehabilitation.
(2) A knee CPM
				  device required for more than twenty-one (21) days does require a PA of the
				  additional days. These cases will be individually reviewed for medical
				  necessity.
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 317:30-5-211.24 - Parenteral nutrition

Current through Vol. 41, No. 20, July 1, 2024
(a)
Parenteral nutrition (PN).
PN is the provision of nutritional
				  requirements intravenously.
(b)
Medical necessity.
PN must be determined by a provider to be
				  medically necessary and documented in the member's plan of care as medically
				  necessary and used for medical purposes. A request by a qualified provider for
				  PN in and of itself shall not constitute medical necessity. The Oklahoma Health
				  Care Authority (OHCA) shall serve as the final authority pertaining to all
				  determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
(1) Hospital records that have objective
				  medical evidence supporting the clinical diagnosis; if applicable;
(2) A certificate of medical
				  necessity;
(3) A prescription;
				  and
(4) Caloric Intake.
(5) For full guidelines, please refer to
www.okhca.org/mau
.
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 317:30-5-211.25 - Continuous glucose monitoring

Current through Vol. 41, No. 20, July 1, 2024
(a)
Continuous glucose monitoring (CGM).
CGM means a minimally
				  invasive system that measures glucose levels in subcutaneous or interstitial
				  fluid. CGM provides blood glucose levels and can help members make more
				  informed management decisions throughout the day.
(b)
Medical necessity.
CGM must
				  be determined by a provider to be medically necessary and documented in the
				  member's plan of care as medically necessary and used for medical purposes. A
				  request by a qualified provider for CGM in and of itself shall not constitute
				  medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the
				  final authority pertaining to all determinations of medical necessity. Refer to
				  Oklahoma Administrative Code (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity. CGM devices must be approved by the U.S. Food
				  and Drug Administration (FDA) as non-adjunctive and must be used for
				  therapeutic purposes. Devices may only be used for members within the age range
				  for which the devices have been FDA approved.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
				  Requests for CGM must include all of the following documentation:
(1) Prescription by a qualified
				  provider;
(2) Member diagnosis that
				  correlates to the use of CGM;
(3)
				  Documentation of the member testing to include the frequency each
				  day;
(4) Documentation member is
				  insulin-treated to include frequency of daily or is using insulin pump
				  therapy;
(5) Documentation member's
				  insulin treatment regimen requires frequent adjustment;
(6) The member and/or family member has
				  participated in age appropriate diabetes education, training, and support prior
				  to beginning CGM; and
(7) In-person
				  or telehealth visit [within the last six (6) months] between the treating
				  provider, member and/or family to evaluate their diabetes control.
(8) For full guidelines please refer to
www.okhca.org/mau
.
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 317:30-5-211.26 - Bathroom equipment

Current through Vol. 41, No. 20, July 1, 2024
(a)
Bathroom equipment.
Bathroom equipment is used for bathing and
				  toileting and may be considered primarily medical in nature if used in the
				  presence of an illness and/or injury and if it is necessary for activities of
				  daily living that are considered to be essential to health and personal
				  hygiene.
(b)
Medical
				  necessity.
Bathroom equipment must be determined by a provider to be
				  medically necessary and documented in the member's plan of care as medically
				  necessary and used for medical purposes. A request by a qualified provider for
				  bathroom equipment in and of itself shall not constitute medical necessity. The
				  Oklahoma Health Care Authority (OHCA) shall serve as the final authority
				  pertaining to all determinations of medical necessity. Refer to Oklahoma
				  Administrative Code (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
(1) Current written prescription for specific
				  medical supply, equipment, and appliance item;
(2) Letter of medical necessity;
(3) Product information;
(4) Manufacturer's suggested retail price
				  (MSRP) for each item requested
(5)
				  For full guidelines, please refer to
www.okhca.org/mau
.
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 317:30-5-211.27 - Positive airway pressure (PAP) devices

Current through Vol. 41, No. 20, July 1, 2024
(a)
PAP devices.
PAP devices are
				  both a single level continuous positive airway pressure device (CPAP), and/or a
				  bi-level respiratory assist device with or without back-up rate when it is used
				  in the treatment of obstructive sleep apnea.
(b)
Medical Necessity.
PAP
				  devices must be determined by a provider to be medically necessary and
				  documented in the member's plan of care as medically necessary and used for
				  medical purposes. A request by a qualified provider for PAP devices in and of
				  itself shall not constitute medical necessity. The Oklahoma Health Care
				  Authority (OHCA) shall serve as the final authority pertaining to all
				  determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
(1) A face-to-face clinical evaluation by the
				  treating qualified medical professional within six (6) months prior to
				  receiving device;
(2) Qualifying
				  polysomnogram that is dated within one (1) year of the prior authorization
				  request submission;
(3) The patient
				  and/or his or her caretaker have received instruction from the supplier of the
				  device in the proper use and care of the equipment; and
(4) Medical records supporting the need for a
				  PAP device.
(5) For full
				  guidelines, please refer to
www.okhca.org/mau
.
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 317:30-5-211.28 - Sleep studies

Current through Vol. 41, No. 20, July 1, 2024
(a)
Sleep
				  studies.
Sleep studies are the continuous and simultaneous monitoring
				  and recording of specified physiological and pathophysiological parameters
				  during a period of sleep for six (6) or more hours. The study is used to
				  diagnose a variety of sleep disorders and to evaluate a patient's response to
				  therapies such as continuous positive airway pressure (CPAP). A sleep study
				  requires physician review, interpretation, and report.
(b)
Medical necessity.
Sleep
				  studies must be determined by a provider to be medically necessary and
				  documented in the member's plan of care as medically necessary and used for
				  medical purposes. A request by a qualified provider for sleep studies in and of
				  itself shall not constitute medical necessity. The Oklahoma Health Care
				  Authority (OHCA) shall serve as the final authority pertaining to all
				  determinations of medical necessity. Refer to Oklahoma Administrative Code
				  (OAC)
				  317:30-5-211.2
				  and
				  317:30-3-1(f)
				  for policy on medical necessity.
(c)
Documentation.
All
				  documentation submitted to request services must demonstrate, through adequate
				  objective medical records, evidence sufficient to justify the member's need for
				  the service, in accordance with OAC
				  317:30-3-1(f)(2).
				  Documentation requirements include:
(1)
				  Legible signature of the qualified provider or non-physician practitioner
				  responsible for and providing the care to the patient;
(2) All pages in the prior authorization
				  request must be clear and legible;
(3) Face-to-face evaluation by the ordering
				  provider, the supervising physician, or the interpreting physician;
				  and
(4) Medical records to support
				  the medical indication for the sleep study including results of sleep
				  scale.
(5) For full guidelines,
				  please refer to
www.okhca.org/mau
.
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 317:30-5-212 - Coverage for children [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 15 Ok Reg 4182, eff 8-5-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99; Amended at 18 Ok Reg 477, eff 1-1-01 (emergency);
					 Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 24 Ok Reg 2890, eff 7-1-07
					 (emergency); Amended at 25 Ok Reg 1161, eff 5-25-08; Revoked at 27 Ok Reg 453,
					 eff 12-3-09 (emergency); Revoked at 27 Ok Reg 942, eff
					 5-13-10
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 317:30-5-213 - Coverage for vocational rehabilitation [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Revoked at 15 Ok Reg 4182, eff 8-5-98 (emergency); Revoked at 16 Ok
					 Reg 1429, eff 5-27-99
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 317:30-5-214 - Coverage for individuals eligible for Part B of Medicare

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to medical suppliers utilizing the Medicaid
					 allowable for comparable services.
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 19 Ok Reg 2922, eff 7-1-02 (emergency); Amended at 20 Ok
					 Reg 1193, eff 5-27-03
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 317:30-5-215 - Billing requirements [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 18 Ok Reg 477, eff 1-1-01 (emergency); Amended at 18 Ok Reg
					 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-02; Revoked at 24 Ok Reg
					 2890, eff 7-1-07 (emergency); Revoked at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-216 - Prior authorization requests [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Revoked at 18 Ok Reg 477, eff 1-1-01 (emergency); Revoked at 18 Ok Reg
					 1130, eff 5-11-01; Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25
					 Ok Reg 1161, eff 5-25-08; Amended at 26 Ok Reg 256, eff 12-1-08 (emergency);
					 Amended at 26 Ok Reg 1062, eff 5-11-09; Amended at 27 Ok Reg 453, eff 12-3-09
					 (emergency); Amended at 27 Ok Reg 942, eff
					 5-13-10
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 317:30-5-217 - Billing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Procedure
				  codes.
It is the supplier's responsibility to ensure that claims for the
				  supply or equipment are submitted with the most appropriate HCPCS code as
				  assigned by the Medicare PDACor its successor. When the most appropriate
				  procedure code is not used, the claim will be denied. When a specific procedure
				  code has not been assigned to an item, an invoice is required which must
				  contain a full description of the equipment or supply.
(b)
Rental.
Claims for rental
				  should indicate the first date of service and the inclusive dates of rental as
				  part of the description of services. The appropriate modifier must be included.
				  Only one month's rental should be entered on each detail line.
(c)
Invoice.
For manually priced
				  items, after the service has been provided, the supplier is required to include
				  a copy of the invoice documenting the supplier's cost of the item with the
				  claim.
(d)
Place of
				  service.
The appropriate indicator for the patient's place of residence
				  must be entered.
(e)
Prescribing provider.
The name of the prescribing provider must be
				  included for claims processing and entered in the appropriate block.
(f)
Proof of Delivery.
Items
				  must be received by the member before billing OHCA. Proof of delivery must be
				  retained by the provider in the member's file and provided to the OHCA upon
				  request. In addition, for manually priced items, evidence of proof of delivery
				  must be attached to the claim for adjudication.
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 18 Ok Reg 477, eff 1-1-01 (emergency); Amended at 18 Ok Reg
					 1130, eff 5-11-01; Amended at 24 Ok Reg 2890, eff 7-1-07 (emergency); Amended
					 at 25 Ok Reg 1161, eff 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-218 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical
				  supplies, equipment and appliances.
Reimbursement for medical supplies,
				  equipment, and appliances will be made using an amount derived from the lesser
				  of the Oklahoma Health Care Authority (OHCA) maximum allowable fee or the
				  provider's usual and customary charge. The maximum allowable fee is the maximum
				  amount that the OHCA will pay a provider for an allowable procedure. When a
				  code is not assigned a maximum allowable fee for a unit of service, a fee will
				  be established.
(1) The fee schedule will be
				  reviewed annually. Adjustments to the fee schedule may be possible at any time
				  based on efficiency, budget considerations, federal regulations, and quality of
				  care as determined by the OHCA.
(2)
				  Payment for medical supplies, equipment, and appliances will be calculated
				  using the rate methodologies found in the Oklahoma Medicaid State
				  Plan.
(3) Payment is not made for
				  medical supplies, equipment, and appliances that are not deemed as medically
				  necessary or considered over-the-counter.
(4) OHCA does not reimburse medical supplies,
				  equipment, and appliances providers separately for services that are included
				  as part of the payment for another treatment program. For example, all items
				  required during inpatient stays are paid through the inpatient payment
				  structure.
(5) Medical supplies,
				  equipment, and appliance products purchased at a pharmacy are paid the
				  equivalent to the Medicare Part B allowed charge. When the Medicare Part B
				  allowed charge is not available, an equivalent price is calculated using ASP or
				  wholesale acquisition cost (WAC). If no Medicare, ASP, or WAC pricing is
				  available, then the price will be calculated based on invoice cost.
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 317:30-5-218 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical
				  supplies, equipment and appliances.
(1)
				  Reimbursement for medical supplies, equipment, and appliances will be made
				  using an amount derived from the lesser of the Oklahoma Health Care Authority
				  (OHCA) maximum allowable fee or the provider's usual and customary charge. The
				  maximum allowable fee is the maximum amount that the OHCA will pay a provider
				  for an allowable procedure. When a code is not assigned a maximum allowable fee
				  for a unit of service, a fee will be established.
(2) The fee schedule will be reviewed
				  annually. Adjustments to the fee schedule may be possible at any time based on
				  efficiency, budget considerations, federal regulations, and quality of care as
				  determined by the OHCA.
(3) Payment
				  for medical supplies, equipment, and appliances will be calculated using the
				  rate methodologies found in the Oklahoma Medicaid State Plan.
(4) Payment is not made for medical supplies,
				  equipment, and appliances that are not deemed as medically necessary or
				  considered over-the-counter.
(5)
				  OHCA does not reimburse medical supplies, equipment, and appliances providers
				  separately for services that are included as part of the payment for another
				  treatment program. For example, all items required during inpatient stays are
				  paid through the inpatient payment structure.
(6) Medical supplies, equipment, and
				  appliance products purchased at a pharmacy are paid the equivalent to Medicare
				  Part B, average sales price (ASP) + six percent (6%). When ASP is not
				  available, an equivalent price is calculated using wholesale acquisition cost
				  (WAC). If no Medicare, ASP, or WAC pricing is available, then the price will be
				  calculated based on invoice cost.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 18 - GENETIC COUNSELORS › Section 317:30-5-219 - General information

Current through Vol. 41, No. 20, July 1, 2024
Genetic counseling gathers critical family history, patient
					 history, and other factors to be analyzed and shared with the member to help
					 them understand and adapt to the medical, psychosocial and familial
					 contributions to potential or realized birth defects.
Added at 25 Ok Reg
					 428, eff 11-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 18 - GENETIC COUNSELORS › Section 317:30-5-220 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Eligible providers must be Licensed Genetic Counselors.
					 Genetic Counselors must have a current contract on file with the Oklahoma
					 Health Care Authority and be licensed in the state in which the service is
					 being provided.
Added at 25 Ok Reg
					 428, eff 11-1-07 (emergency); Added at 25 Ok Reg 1161, eff
					 5-25-08