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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-659 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
					 shall have the following meaning, unless the context clearly indicates
					 otherwise:
"APRN"
means advanced practice registered
					 nurse.
"C.F.R"
means the U.S. Code of Federal
					 Regulations.
"CLIA"
means the Clinical Laboratory
					 Improvement Amendments.
"CMS"
means the Centers for Medicare and
					 Medicaid Services.
"CNM"
means certified nurse midwife.
"Core services"
means outpatient services that
					 may be covered when furnished to a patient at the Center or other location,
					 including the patient's place of residence.
"CPT"
means current procedural terminology.
"CSW"
means clinical social worker.
"Encounter"
or
"visit"
means a
					 face-to-face contact between an approved health care professional as authorized
					 in the FQHC pages of the Oklahoma Medicaid State Plan and an eligible
					 SoonerCare member for the provision of defined services through a Health Center
					 within a twenty-four (24) hour period ending at midnight, as documented in the
					 patient's medical record.
"FFS"
means the current OHCA's fee-for-service
					 reimbursement rate.
"FQHC"
means Federally Qualified Health
					 Center.
"HHS"
means the U.S. Department of Health and
					 Human Services.
"HRSA"
means the Health Resources and Services
					 Administration.
"Licensed behavioral health professional
					 (LBHP)
means any of the following practitioners:
(A) An allopathic or osteopathic physician
				  with a current license and board certification in psychiatry or board eligible
				  in the state in which services are provided, or a current resident in
				  psychiatry practicing as described in OAC
				  317:30-5-2.
(B) A practitioner with a current
				  license to practice in the state in which services are provided, within one (1)
				  of the areas of practice listed in (i) through (vi).
(i) Psychology;
(ii) Social work (clinical specialty only);
(iii) Professional counselor;
(iv) Marriage and family
				  therapist;
(v) Behavioral
				  practitioner; or
(vi) Alcohol and
				  drug counselor.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
(a) FQHCs are
				  community-based health care providers that receive federal funds to provide
				  primary care services in underserved areas. FQHCs may be Community Health
				  Centers, Migrant Health Centers, Health Care for the Homeless, and Health
				  Centers for Residents of Public Housing. The facilities in this Part may also
				  be referred to as "Health Centers" or "Centers".
(b) To qualify as an FQHC SoonerCare
				  provider, Health Centers must meet one (1) of the following requirements:
(1) Received a grant under Section 330 of the
				  Public Health Service (PHS) Act or is funded by the same grant contracted to
				  the recipient;
(2) Based on the
				  recommendation of the Health Resources and Services Administration within the
				  Public Health Service, is determined by the Secretary to meet the requirements
				  for receiving such a grant, which qualifies the entity as an "FQHC look-alike";
(3) Treated by the Secretary of
				  HHS as a comprehensive federally funded health center; or
(4) Operating as an outpatient health program
				  or facility of a tribe or tribal organization under the Indian
				  Self-Determination Act or as an urban Indian organization getting funds under
				  Title V of the Indian Health Care Improvement Act.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.1 - Health Center multiple sites contracting

Current through Vol. 41, No. 20, July 1, 2024
(a) Health Centers may contract as SoonerCare
				  Traditional providers and as a PCP under SoonerCare Choice (Refer to OAC
				  317:25-7-5)
				  .
(b) Health Centers are required
				  to submit a list of all entities affiliated or owned by the Center including
				  any programs that do not have Health Center status, along with all OHCA
				  provider numbers.
(c) Payment for
				  FQHC services is based on a PPS reimbursement . (Refer to OAC
				  317:30-5-664.10)
				  In order to be eligible for reimbursement under this method for covered
				  services, in traditional primary care settings, each site must submit an
				  approval copy of the HRSA Notice of Grant Award Authorization for Public Health
				  Services Funds under Section 330, (or a copy of the recommendation letter from
				  the HRSA designating the facility as a "Look Alike" FQHC) at the time of
				  enrollment.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.2 - Health Center professional staff

Current through Vol. 41, No. 20, July 1, 2024
(a) Health Centers must either directly
				  employ or contract the services of professional staff who is licensed or
				  certified and in good standing in the state in which services are provided.
				  Services must be within the scope of the professional's license or
				  certification for which claims are submitted to OHCA or its designated agent.
(b) Professional staff contracted
				  or employed by the Health Center recognized by the OHCA for direct
				  reimbursement are required to individually enroll with the OHCA and will be
				  affiliated with the organization which contracts or employs them. Participating
				  Health Centers are required to submit a list of names upon request of all
				  practitioners working within the Center and a list of all individual OHCA
				  provider numbers. Reimbursement for services rendered at or on behalf of the
				  Health Center is made to the organization. Practitioners eligible for direct
				  reimbursement for providing services to a clinic patient outside of the clinic
				  may bill with their individual assigned number if they are not compensated
				  under agreement by the Health Center.
(c) Other providers who are not eligible for
				  direct reimbursement may be recognized by OHCA for the provision and payment of
				  FQHC services to a health center as long as they are licensed or certified in
				  good standing and meet OHCA enrollment requirements .
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.3 - Health Center enrollment requirements for specialty behavioral health services

Current through Vol. 41, No. 20, July 1, 2024
For the provision of behavioral health related case
					 management services and psychosocial rehabilitation services, Health Centers
					 must contract as an outpatient behavioral health agency and meet the
					 requirements found at OAC
					 317:30-5-241.3 and
					 317:30-5-241.6.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.3 - Health Center enrollment requirements for specialty behavioral health services

Current through Vol. 41, No. 20, July 1, 2024
(a) For the
				  provision of behavioral health related case management services and
				  psychosocial rehabilitation services, Health Centers must contract as an
				  outpatient behavioral health agency and meet the requirements found at OAC
				  317:30-5-241.3
				  and
				  317:30-5-241.6.
(b) Health Centers which provide
				  substance use treatment services must also be certified by the Oklahoma
				  Department of Mental Health and Substance Abuse Services (ODMHSAS).
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.4 - Health Center enrollment requirements for health services in a school setting

Current through Vol. 41, No. 20, July 1, 2024
(a) Physical and
				  behavioral health services provided in accordance with the Individuals with
				  Disabilities Education Act (IDEA) and pursuant to an Individual Education Plan
				  (IEP) or Individual Family Service Plan (IFSP) are the responsibility of the
				  school district. Health Centers must contract with the school district and
				  invoice the school district for services rendered. (Refer to OAC
				  317:30-5-1020
				  through 30-5-1027). Reimbursement is made directly to the school.
(b) Payment may be made for FQHC services to
				  Health Centers that have a school-based health center that meets the definition
				  of Section 2110(c)(9) of the Social Security Act.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-660.5

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661

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 13 Ok Reg 411, eff 11-14-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Amended at 16 Ok Reg 141, eff 10-14-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 19 Ok Reg 2922, eff 7-1-02
					 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 23 Ok Reg 3183,
					 eff 6-7-06 (emergency); Amended at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.1 - Coverage of core services

Current through Vol. 41, No. 20, July 1, 2024
Health Center services are covered for SoonerCare adults
					 and children as set forth in this Part, unless otherwise specified.
(1) Services furnished by a physician, PA,
				  APRN, CNM, CP, or CSW.
(2) Services
				  and supplies incident to services provided by a physician, PA, APRN, CNM, CP,
				  or CSW are covered in accordance with
				  42 C.F.R
				  §§
											405.2413 and
				  405.2415,
				  if the service or supply is:
(A) Furnished in
				  accordance with State law;
(B) A
				  type commonly furnished in physicians' offices;
(C) A type commonly rendered either without
				  charge or included in the FQHC's bill;
(D) Furnished as an incidental, although
				  integral, part of a physician, PA, APRN, CNM, CP or CSW services; or
(E) Furnished under the direct supervision of
				  a physician PA, APRN, or CNM; and
(F) Drugs and biologicals which cannot be
				  self-administered or are specifically covered by Medicare law, are included
				  within the scope of FQHC services. Drugs and biologicals commonly used in life
				  saving procedures, such as analgesics, anesthetics (local), antibiotics,
				  anticonvulsants, antidotes and emetics, serums and toxoids are not billed
				  separately.
(G) "Services and
				  supplies incident to" include but are not limited to services such as minor
				  surgery, reading x-rays, setting casts or simple fractures and other activities
				  that involve evaluation or treatment of a patient's condition. They also
				  include laboratory services performed by the Health Center, specimen collection
				  for laboratory services furnished by an off-site CLIA certified laboratory and
				  injectable drugs.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.2

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.3

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.4 - Behavioral health professional services provided at Health Centers and other settings

Current through Vol. 41, No. 20, July 1, 2024
(a) Medically
				  necessary behavioral health services that are primary, preventive, and
				  therapeutic and that would be covered if provided in another setting may be
				  provided by Health Centers. Services provided by a Health Center (refer to OAC
				  317:30-5-241 for
				  a description of services) must meet the same requirements as services provided
				  by other behavioral health providers. Rendering providers must be eligible to
				  individually enroll or meet the requirements as an agency/organization provider
				  specified in OAC
				  317:30-5-240.2
				  and
				  317:30-5-280.
				  Behavioral Health Services include:
(1)
				  Assessment/Evaluation;
(2) Crisis
				  Intervention Services;
(3)
				  Individual/Interactive Psychotherapy;
(4) Group Psychotherapy;
(5) Family Psychotherapy;
(6) Psychological Testing; and
(7) Case Management (as an integral component
				  of services 1-6 above).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.5 - Health Center preventive primary care services

Current through Vol. 41, No. 20, July 1, 2024
(a) Preventive primary care services, as
				  described in
				  42 C.F.R §
											405.2448, are those health services that:
(1) A Health Center is required to provide as
				  preventive primary health services under section 330 of the Public Health
				  Service Act;
(2) Are furnished by
				  or under the direct supervision of a physician, PA, APRN, CNM, CP, CSW or other
				  approved health care professional as authorized in the approved FQHC State Plan
				  pages;
(3) Are furnished by a
				  member of the Health Center's health care staff who is an employee of the
				  Center or provides services under arrangements with the Center; and
(4) Includes only drugs and biologicals that
				  cannot be self-administered.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.6

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-661.7 - Allowable Places of services

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Services provided to members within the four walls of the Health Center and
				  approved Health Center satellites including mobile health clinics operated by
				  the Center are allowable for reimbursement under the PPS.
(b) Off-site services provided by employed
				  practitioners of the Health Center to patients temporarily homebound or in any
				  skilled nursing facility because of a medical condition that prevents the
				  patient from going to the Health Center for health care are also allowable for
				  reimbursement under the PPS encounter rate if the service would be reimbursed
				  the PPS at the Center. It is expected that services provided in off-site
				  settings should be, in most cases, temporary and intermittent, i.e., when the
				  member cannot come to the clinic due to health reasons.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-662 - Reimbursement [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 23 Ok Reg 3183, eff 6-7-06 (emergency); Revoked at 24 Ok
					 Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-663 - Billing [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 13 Ok Reg 411, eff 11-14-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Amended at 16 Ok Reg 141, eff 10-14-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 19 Ok Reg 2134, eff 6-27-02;
					 Revoked at 23 Ok Reg 3183, eff 6-7-06 (emergency); Revoked at 24 Ok Reg 2105,
					 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664 - Timely filing [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 19 Ok Reg 2134, eff 6-27-02; Revoked at 23 Ok Reg 3183, eff
					 6-7-06 (emergency); Revoked at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.1 - Provision of other health services outside of the Health Center core services

Current through Vol. 41, No. 20, July 1, 2024
(a) If the Center
				  chooses to provide other Oklahoma Medicaid State Plan covered health services
				  which are not included in the Health Center core service definition in OAC
				  317:30-5-661.1,
				  the practitioners of those services are subject to the same program coverage
				  limitations, enrollment, and billing procedures described by the OHCA, and
				  these services (e.g., home health services) are not included in the Prospective
				  Payment System settlement methodology in OAC
				  317:30-5-664.12.
(b) Other medically necessary health services
				  that will be reimbursed at the fee-for-service rate include, but are not
				  limited to:
(1) Dental services (refer to OAC
				  317:30-5-696)
				  except for primary preventive dental services;
(2) Eyeglasses (refer to OAC
				  317:30-5-431,
				  317:30-5-432.1
				  and
				  317:30-5-451);
(3) Clinical lab tests performed in the
				  Center lab (other than the specific laboratory tests set out for Health
				  Centers' certification and covered as Health Center services);
(4) Technical component of diagnostic tests
				  such as x-rays and EKGs (interpretation of the test provided by the Center
				  physician is included as physician professional services);
(5) Durable medical equipment (refer to OAC
				  317:30-5-210);
(6) Transportation by ambulance (refer to OAC
				  317:30-5-335);
(7) Prescribed drugs (refer to OAC
				  317:30-5-70);
(8) Prosthetic devices (other than dental)
				  which replace all or part of an internal body organ (including colostomy bags)
				  and supplies directly related to colostomy care and the replacement of such
				  devices;
(9) Specialized laboratory
				  services furnished away from the clinic;
(10) Psychosocial rehabilitation services
				  (refer to OAC
				  317:30-5-241.3);
(11) Behavioral health related case
				  management services (refer to OAC
				  317:30-5-241.6);
				  and
(12) Applied behavior analysis
				  (ABA) (refer to OAC
				  317:30-3-65.12)
				  .
(13) Diabetes self-management
				  education and support (DSMES) services (refer to OAC 317:30-5-1080 through
				  317:30-5-1084) .
(14) Long-acting
				  reversible contraceptive devices (devices are not considered part of the FQHC
				  encounter rate and can be billed separately).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.2 - Prior authorization and referrals

Current through Vol. 41, No. 20, July 1, 2024
(a) Health Center encounters for core
				  services, whether medical or behavioral health, are not subject to prior
				  authorization. However, some Health Center services may require a referral from
				  a PCP/CM.
(b) Other SoonerCare
				  State Plan covered health services that the Center chooses to provide are
				  subject to all applicable Medicaid regulations which govern the provision and
				  coverage for that service.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.3 - Federally Qualified Health Center (FQHC) encounters

Current through Vol. 41, No. 20, July 1, 2024
(a) FQHC encounters
				  that are billed to the Oklahoma Health Care Authority (OHCA) must meet the
				  definition in this Section and are limited to services covered by OHCA. Only
				  encounters provided by an authorized health care professional listed in the
				  approved FQHC State Plan pages within the scope of their licensure trigger a
				  Prospective Payment System (PPS) encounter rate.
(b) An encounter is defined as a face-to-face
				  contact between a health care professional and a member for the provision of
				  defined services through a FQHC within a twenty-four (24) hour period ending at
				  midnight, as documented in the member's medical record. Services delivered via
				  audio-only telecommunications do not constitute an encounter.
(c) An FQHC may bill for one (1) medically
				  necessary encounter per twenty-four (24) hour period when the appropriate
				  modifier is applied. Medical review will be required for additional visits for
				  children. For information about multiple encounters, refer to Oklahoma
				  Administrative Code (OAC)
				  317:30-5-664.4. Payment is
				  limited to four (4) visits per member per month for adults. This limit may be
				  exceeded if the SoonerCare Choice member has elected the FQHC as his/her/their
				  Patient Centered Medical Home/Primary Care Provider.
(d) Services considered reimbursable
				  encounters (including any related medical supplies provided during the course
				  of the encounter) include:
(1)
				  Medical;
(2) Diagnostic;
(3) Dental, medical and behavioral health
				  screenings;
(4) Vision;
(5) Physical therapy;
(6) Occupational therapy;
(7) Podiatry;
(8) Behavioral health;
(9) Speech;
(10) Hearing;
(11) Medically necessary FQHC encounters with
				  a registered nurse or licensed practical nurse and related medical supplies
				  (other than drugs and biologicals) furnished on a part-time or intermittent
				  basis to home-bound members (refer to OAC
				  317:30-5-661.3) ; and
(12) Any other medically necessary health
				  services (i.e. optometry and podiatry) are also reimbursable as permitted
				  within the FQHCs scope of services when medically reasonable and necessary for
				  the diagnosis or treatment of illness or injury, and must meet all applicable
				  coverage requirements.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.3 - FQHC encounters

Current through Vol. 41, No. 20, July 1, 2024
(a) FQHC encounters
				  that are billed to the OHCA must meet the definition in this Section and are
				  limited to services covered by OHCA. Only encounters provided by an authorized
				  health care professional listed in the approved FQHC State Plan pages within
				  the scope of their licensure trigger a PPS encounter rate.
(b) An encounter is defined as a face-to-face
				  contact between a health care professional and a member for the provision of
				  defined services through a FQHC within a twenty-four (24) hour period ending at
				  midnight, as documented in the member's medical record.
(c) An FQHC may bill for one (1) medically
				  necessary encounter per twenty-four (24) hour period when the appropriate
				  modifier is applied. Medical review will be required for additional visits for
				  children. For information about multiple encounters, refer to OAC
				  317:30-5-664.4.
				  Payment is limited to four (4) visits per member per month for adults. This
				  limit may be exceeded if the SoonerCare Choice member has elected the FQHC as
				  his/her/their Patient Centered Medical Home/Primary Care Provider.
(d) Services considered reimbursable
				  encounters (including any related medical supplies provided during the course
				  of the encounter) include:
(1)
				  Medical;
(2) Diagnostic;
(3) Dental, medical and behavioral health
				  screenings;
(4) Vision;
(5) Physical therapy;
(6) Occupational therapy;
(7) Podiatry;
(8) Behavioral health;
(9) Speech;
(10) Hearing;
(11) Medically necessary FQHC encounters with
				  a registered nurse or licensed practical nurse and related medical supplies
				  (other than drugs and biologicals) furnished on a part-time or intermittent
				  basis to home-bound members (refer to OAC
				  317:30-5-661.3);
				  and
(12) Any other medically
				  necessary health services (i.e. optometry and podiatry) are also reimbursable
				  as permitted within the FQHCs scope of services when medically reasonable and
				  necessary for the diagnosis or treatment of illness or injury, and must meet
				  all applicable coverage requirements.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.4 - Multiple encounters at Federally Qualified Health Centers (FQHC)

Current through Vol. 41, No. 20, July 1, 2024
An FQHC may bill for more than one (1) medically necessary
					 encounter per 24-hour period under certain conditions when the appropriate
					 modifier is applied.
(1) It is
				  intended that multiple medically necessary encounters will occur on an
				  infrequent basis.
(2) An FQHC may
				  not develop FQHC procedures that routinely involve multiple encounters for a
				  single date of service, unless medical necessity warrants multiple
				  encounters.
(3) Each service must
				  have distinctly different diagnoses in order to meet the criteria for multiple
				  encounters. For example, a medical visit and a dental visit on the same day are
				  considered different services with distinctly different diagnoses.
(4) Similar services, even when provided by
				  two (2) different health care practitioners, are not considered multiple
				  encounters.
(5) Encounters with
				  more than one (1) FQHC practitioner on the same day, regardless of the length
				  or complexity of the visit, would constitute a single visit. An exception is
				  when the patient has either or both of these:
(A) An illness or injury requiring additional
				  diagnosis or treatment subsequent to the first encounter; and/or
(B) A qualified medical visit, a qualified
				  mental health and/or dental visit on the same day.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.5 - Federally Qualified Health Center (FQHC) encounter exclusions and limitations

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Service limitations governing the provision of all services apply pursuant to
				  Oklahoma Administrative Code (OAC) 317:30. Excluded from the definition of
				  reimbursable encounter core services are:
(1)
				  Services provided by an independently Clinical Laboratory Improvement
				  Amendments certified and enrolled laboratory;
(2) Radiology services including nuclear
				  medicine and diagnostic ultrasound services;
(3) Venipuncture for lab tests is considered
				  part of the encounter and cannot be billed separately. When a member is seen at
				  the clinic for a lab test only, use the appropriate Current Procedural
				  Terminology code. A visit for "lab test only" is not considered a Center
				  encounter;
(4) Medical supplies,
				  equipment, and appliances not generally provided during the course of a Center
				  visit such as diabetic supplies. However, gauze, band-aids, or other disposable
				  products used during an office visit are considered as part of the cost of an
				  encounter and cannot be billed separately under SoonerCare;
(5) Supplies and materials that are
				  administered to the member are considered a part of the physician's or other
				  health care practitioner's service;
(6) Drugs or medication treatments provided
				  during a clinic visit are included in the encounter rate. For example, a member
				  has come into the Center with high blood pressure and is treated at the Center
				  with a hypertensive drug or drug samples provided to the Center free of charge
				  are not reimbursable services and are included in the cost of an encounter.
				  Prescriptions are not included in the encounter rate and must be billed through
				  the pharmacy program by a qualified enrolled pharmacy;
(7) Administrative medical examinations and
				  report services;
(8) Emergency
				  services including delivery for pregnant members that are eligible under the
				  Non-Qualified (ineligible) provisions of OAC
				  317:35-5-25;
(9) SoonerPlan family planning
				  services;
(10) Long-acting
				  reversible contraceptive devices (devices are not considered part of the FQHC
				  encounter rate and can be billed separately);
(11) Optometry and podiatric services other
				  than for dual eligible for Part B of Medicare;
(12) Diabetes self-management education and
				  support (DSMES) services (refer to OAC 317:30-5-1080 through 317:30-5-1084);
				  and
(13) Other services that are
				  not defined in this rule or the Oklahoma Medicaid State Plan.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.6 - Prescription drugs purchased under the 340B Drug Discount Program provided by Health Centers

Current through Vol. 41, No. 20, July 1, 2024
For 340B Drug Discount Program guidelines, refer to section
					 317:30-5-87.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.7 - Dental services provided by Health Centers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
The Health Center
				  core service benefit to adults is intended to provide services requiring
				  immediate treatment, relief of pain and/or extraction and is not intended to
				  restore teeth as described in OAC
				  317:30-5-696.
				  Core services are limited to treatment for conditions such as:
(1) Acute infection;
(2) Acute abscesses;
(3) Severe tooth pain; and
(4) Tooth re-implantation, when clinically
				  appropriate.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.8 - Obstetrical care provided by Health Centers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Billing written agreement.
In order to avoid duplicative billing situations, a Health Center must have a
				  written agreement with its physician, certified nurse midwife, advanced
				  practice nurse, or physician assistant that specifically identifies how
				  obstetrical care will be billed. The agreement must specifically identify the
				  service provider's compensation for Health Center core services and other
				  health services that may be provided by the Health Center.
(b)
Prenatal or postpartum
				  services.
(1) If the Health Center
				  compensates the physician, certified nurse midwife or advanced practice nurse
				  for the provision of obstetrical care, then the Health Center bills the
				  Oklahoma Health Care Authority (OHCA) for each prenatal and postpartum visit
				  separately using the appropriate Current Procedural Terminology (CPT)
				  evaluation and management code(s) as provided in the Health Center billing
				  manual.
(2) If the clinic does not
				  compensate the provider for the provision of obstetrical care, then the
				  provider must bill the OHCA for prenatal care according to the global method
				  described in the SoonerCare Traditional provider specific rules for physicians,
				  certified nurse midwives, physician assistants, and advanced practice nurses [
				  refer to Oklahoma Administrative Code (OAC)
				  317:30-5-22 ].
(3) Under both billing methods, payment for
				  prenatal care includes all routine or minor medical problems. No additional
				  payment is made to the prenatal provider except in the case of a major illness
				  distinctly unrelated to pregnancy.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.9 - Family planning services provided by Health Centers

Current through Vol. 41, No. 20, July 1, 2024
Family planning services provided to SoonerCare Traditional
					 and Choice members are considered Health Center core
					 services.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.10 - Health Center reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				  with Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and
				  Protection Act (BIPA) of 2000, reimbursement is provided for core services and
				  other health services at a Health Center facility-specific Prospective Payment
				  System (PPS) rate per visit (encounter) determined according to the methodology
				  described in Oklahoma Administrative Code (OAC)
				  317:30-5-664.12.
(b) As claims/encounters are filed,
				  reimbursement for SoonerCare Choice members is made for all medically necessary
				  covered primary care and other approved health services at the PPS rate, except
				  for services delivered via audio-only telecommunications which are reimbursed
				  at the fee-for-service (FFS) rate pursuant to the FFS fee schedule.
(c) Primary and preventive behavioral health
				  services rendered by health care professionals authorized in the Federally
				  Qualified Health Center (FQHC) approved state plan pages will be reimbursed at
				  the PPS encounter rate, except for services delivered via audio-only
				  telecommunications which are reimbursed at the FFS rate pursuant to the FFS fee
				  schedule.
(d) Vision services
				  provided by Optometrists within the scope of their licensure for non-dual
				  eligible members and allowed under the Medicaid State Plan are reimbursed
				  pursuant to the SoonerCare FFS fee schedule.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.10 - Health Center reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				  with Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and
				  Protection Act (BIPA) of 2000, reimbursement is provided for core services and
				  other health services at a Health Center facility-specific Prospective Payment
				  System (PPS) rate per visit (encounter) determined according to the methodology
				  described in OAC
				  317:30-5-664.12.
(b) As claims/encounters are
				  filed, reimbursement for SoonerCare Choice members is made for all medically
				  necessary covered primary care and other approved health services at the PPS
				  rate.
(c) Primary and preventive
				  behavioral health services rendered by health care professionals authorized in
				  the FQHC approved state plan pages will be reimbursed at the PPS encounter
				  rate.
(d) Vision services provided
				  by Optometrists within the scope of their licensure for non - dual eligible
				  members and allowed under the Medicaid State Plan are reimbursed pursuant to
				  the SoonerCare fee-for-service fee schedule.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Amended at
					 26 Ok Reg 249, eff 1-1-09 (emergency); Amended at 26 Ok Reg 1053, eff 5-11-09;
					 Amended at 28 Ok Reg 123, eff 10-14-10 (emergency); Amended at 28 Ok Reg 1443,
					 eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.11 - PPS rate reconciliation to Health Centers [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, eff 6-25-07; Revoked at
					 28 Ok Reg 123, eff 10-14-10 (emergency); Revoked at 28 Ok Reg 1443, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.12 - Determination of Health Center PPS rate

Current through Vol. 41, No. 20, July 1, 2024
(a)
Methodology.
The methodology
				  for establishing each facility's PPS rate is found in Attachment 4.19 B of the
				  OHCA's State Plan, as amended effective January 1, 2001, and incorporated
				  herein by reference.
(b)
Scope of service adjustment.
If a Center significantly changes its
				  scope of services, the Center may request in writing that new baseline
				  encounter rates be determined. Adjustments to encounter rates are made if it is
				  determined that a significant change in the scope-of-service has occurred which
				  impacts the base rate, as indicated within the State Plan. If there is a change
				  in scope-of-service, it is the responsibility of the FQHC to request OHCA to
				  review services that have had a change to the scope-of-service. The OHCA may
				  initiate a rate adjustment in accordance with procedures in the State Plan,
				  based on audited financial statements or cost reports, if the scope of services
				  has been modified or would otherwise result in a change to the Center's current
				  rate. If a new rate is set, the rate will be effective on the date the change
				  in scope-of-service was implemented.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.13 - Individuals eligible for Part B of Medicare

Current through Vol. 41, No. 20, July 1, 2024
For individuals eligible for Part B of Medicare, payment is
					 made utilizing the SoonerCare allowable for comparable
					 services.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.14 - Health Center record keeping

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Adequate records must be maintained to show what services were provided in the
				  encounter claimed.
(b) All
				  outpatient behavioral health services must be reflected by documentation in the
				  patient records in accordance with OAC
				  317:30-5-248.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 75 - FEDERALLY QUALIFIED HEALTH CENTERS › Section 317:30-5-664.15 - Health Center cost reporting

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  All Health Centers requesting SoonerCare reimbursement must complete an annual
				  report, in a format prescribed by the OHCA, covering a 12-month period of
				  operations based upon the Center's reporting period, to accommodate all
				  allowable costs.
(b) Health Centers
				  that have several sites must file the required cost report.
(c) The cost report may be used to adjust
				  payments based on increases or decreases in change in scope of services
				  provided.
(d) Health Centers select
				  the annual period for reporting purposes, subject to approval by the
				  OHCA.
(e) Once the Health Center
				  has selected a reporting period and obtained the approval of the OHCA, the
				  Center must adhere to the period initially selected unless a change has been
				  authorized in writing by the OHCA. Such a change is made only after the OHCA
				  has established that the reason for such a change is valid.
(f) Periodically, the OHCA may contract for
				  an independent audit of the Health Center's cost report.
Added at 23 Ok Reg
					 3183, eff 6-7-06 (emergency); Added at 24 Ok Reg 2105, 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 77 - SPEECH-LANGUAGE PATHOLOGISTS, SPEECH-LANGUAGE PATHOLOGY ASSISTANTS, CLINICAL FELLOWS AND AUDIOLOGISTS › Section 317:30-5-675 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Speech-language pathologist (SLP).
(1) Must be appropriately licensed in good
				  standing in the state in which they practice and working in accordance with the
				  Speech-Language Pathology and Audiology Licensing Act or other applicable
				  statute(s); and
(2) Entered into a
				  Provider Agreement with the Oklahoma Health Care Authority (OHCA) to provide
				  speech-language pathology services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 77 - SPEECH-LANGUAGE PATHOLOGISTS, SPEECH-LANGUAGE PATHOLOGY ASSISTANTS, CLINICAL FELLOWS AND AUDIOLOGISTS › Section 317:30-5-676 - Coverage by category; payment rates and procedure codes

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage.
Payment is made
				  for speech and hearing services as set forth in this Section.
(1)
Children.
Coverage for
				  children is as follows:
(A)
Preauthorization required.
All therapy services, including the
				  initial evaluation, must be prior authorized. Prior to the initial evaluation,
				  the therapist must have on file a signed and dated prescription or referral for
				  the therapy services from the member's physician or other licensed practitioner
				  of the healing arts. The prescribing or referring provider must be able to
				  provide, if requested, clinical documentation from the member's medical record
				  that supports the medical necessity for the evaluation and referral.
(B)
Speech-language pathology
				  services.
(i) Speech-language
				  pathology services may include speech-language evaluations, individual and
				  group therapy services provided by a fully licensed and certified
				  speech-language pathologist, a licensed speech-language pathology clinical
				  fellow, and services within the scope of practice of a speech-language
				  pathology assistant as directed by the supervising speech-language pathologist,
				  as listed in Oklahoma Administrative Code (OAC)
				  317:30-5-675(a)
				  through (c).
(ii) Initial evaluations must be prior
				  authorized and provided by a fully licensed speech-language
				  pathologist.
(C)
Hearing aids.
Hearing and hearing aid evaluations include pure
				  tone air, bone and speech audiometry by a state licensed audiologist. Payment
				  is made for a hearing aid following a recommendation by a medical or
				  osteopathic physician and a hearing aid evaluation by a state licensed
				  audiologist.