reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 9 - Health Access Networks › Section 317:25-9-3 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) In order to be
				eligible for payment, Health Access Networks (HANs) must have on file with the
				Oklahoma Health Care Authority (OHCA) an approved Provider Agreement. Through
				this agreement, the HAN assures that OHCA's requirements are met and assures
				compliance with all applicable federal and state regulations.
(b) The HAN will be reimbursed a per member
				per month (PMPM) rate based on the number of member months paid to the PCPs
				affiliated with the HAN. OHCA reserves the right to limit reimbursement based
				on availability of funds.
Added at 28 Ok Reg 8,
				  eff 8-13-10 (emergency); Added at 28 Ok Reg 1389, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 11 - Health Management Program › Section 317:25-11-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Subchapter is to describe the rules
				  governing the Health Management Program (HMP) participating in the statewide
				  SoonerCare program. The rules provide assurances that the HMP will work with
				  providers to coordinate and improve the quality of care for SoonerCare members.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 11 - Health Management Program › Section 317:25-11-2 - Requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) The Health
				Management Program (HMP) is a voluntary program offered statewide and serves
				SoonerCare Choice members ages four (4) through sixty-three (63) with or at
				risk for chronic illness who are at the highest risk for adverse outcome and
				increased health care expenditures.
(b) HMP services are grounded in motivational
				interviewing and evidence-based guidelines. The HMP services are designed by
				the HMP vendor and approved by the Oklahoma Health Care Authority (OHCA). The
				HMP vendor's activities may include services delivered directly to SoonerCare
				Choice members or activities in connection with health care providers that are
				designed to benefit SoonerCare Choice members. HMP activities/services can
				include:
(1) Health coaching;
(2) Practice facilitation;
(3) Health navigation;
(4) Performance improvement projects; and
(5) Transition of care assistance.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 11 - Health Management Program › Section 317:25-11-3 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
The Health Management Program (HMP) vendor must have an
				  approved Provider Agreement on file. Through this agreement, the HMP assures
				  that the Oklahoma Health Care Authority's requirements are met and assures
				  compliance with all applicable federal and state regulations. HMPs are not a
				  service delivery system.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 1 - General Provisions › Section 317:30-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
(a) The purpose of
				this Chapter is to detail rules applicable to providers of medical services
				purchased by the Oklahoma Health Care Authority (OHCA).
(b) This Chapter contains basic information
				concerning the SoonerCare Program. It is intended for use by all providers of
				medical and health related services participating in the program. Subchapters
				one, three and seven are applicable to all medical providers, while Subchapter
				five consists of rules unique to a specific type of provider, services, or
				specialty.
(1) The Chapter contains Sections
				dealing with provider policies, coverage of medical and health services, and
				other general program policies and procedures applicable to all
				providers.
(2) Providers and their
				office staff are urged to familiarize themselves with the contents of this
				Chapter and to refer to it when questions arise. Use of the Chapter will reduce
				misunderstandings concerning the coverage and reimbursement of SoonerCare
				services and the Agency's expectations of providers. As users of the rules in
				this Chapter, OHCA also solicits suggestions and comments from
				providers.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 1 - General Provisions › Section 317:30-1-2 - Authority responsibility; fiscal agent

Current through Vol. 41, No. 20, July 1, 2024
(a) As the single State Agency, the Oklahoma
				Health Care Authority (OHCA) administers the medical programs which make
				available appropriate medical services to eligible individuals through the
				Title XIX Medicaid Program. OHCA is directly responsible for administration of
				the medical programs including development of policy, establishment of payment
				rates, certain provider hearings, and provider relations.
(b) The Authority contracts with a fiscal
				agent for operation of the medical claims processing system. The Fiscal Agent
				is responsible for processing all medical claims for individuals eligible under
				the Authority's medical programs and will make payment for services based on
				established policy and procedures.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 1 - General Provisions › Section 317:30-1-3 - Description of rules [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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 1 - General Provisions › Section 317:30-1-4 - 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:
"Adult"
means an individual twenty-one (21)
				  years of age or older, unless otherwise specified by statute, regulation,
				  and/or policy adopted by the Oklahoma Health Care Authority (OHCA). For
				  eligibility criteria policy for children and adults, please refer to Oklahoma
				  Administrative Code (OAC)
				  317:35-5-2.
"Alien"
means an individual who does not have
				  United States citizenship and is not a United States national. It is synonymous
				  with the word "noncitizen".
"CMS"
means the Centers for Medicaid and
				  Medicaid Services.
"Child"
means an individual under twenty-one
				  (21) years of age, unless otherwise specified by statute, regulation, and/or
				  policy adopted by the OHCA. For eligibility criteria policy for children and
				  adults, please refer to OAC
				  317:35-5-2.
"Diagnosis Related Group"
means a patient
				  classification system that relates types of patients treated to the resources
				  they consume.
"Expansion Adult"
means an individual defined by
				  42 Code of Federal Regulations § 435.119 who is age nineteen (19) or older
				  and under sixty-five (65), at or below 133 percent of the federal poverty level
				  (FPL), and who are not categorically related to the aged, blind, and disabled.
"Habilitation"
means health care services that
				  are aimed at helping people gain certain new skills, abilities, knowledge and
				  functioning for daily living.
"Noncitizen"
means an individual who does not
				  have United States citizenship and is not a United States national. It is
				  synonymous with the word "alien".
"OKDHS"
means the Oklahoma Department of Human
				  Services which is also referenced in rules as Department of Human Services
				  (DHS) and Office of Human Services (OHS).
"Rehabilitation"
means health care services that
				  help a person to re-gain skills, abilities or knowledge that may have been lost
				  or compromised as a result of acquiring a disability, or due to a change in
				  one's disability or circumstances.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-2 - Provider agreements

Current through Vol. 41, No. 20, July 1, 2024
In order to be eligible for payment, providers must have on
					 file with OHCA, an approved Provider Agreement. Through this agreement, the
					 provider certifies all information submitted on claims is accurate and
					 complete, assures that the State Agency's requirements are met and assures
					 compliance with all applicable Federal and State regulations. These agreements
					 are renewed at least every 5 years with each provider.
(1) The provider further assures compliance
				  with Section 1352, Title 31 of the U.S. Code and implemented at 45 CFR Part 93
				  which provides that if payments pursuant to services provided under Medicaid
				  are expected to exceed $100,000.00, the provider certifies federal funds have
				  not been used nor will they be used to influence the making or continuation of
				  the agreement to provide services under Medicaid. Upon request, the Authority
				  will furnish a standard form to the provider for the purpose of reporting any
				  non-federal funds used for influencing agreements.
(2) The provider assures in accordance with
				  31
				  USC 6101, Executive Order 12549, that they
				  are not presently or have not in the last three years been debarred, suspended,
				  proposed for debarment or declared ineligible by any Federal department or
				  agency.
(3) For information
				  regarding Provider Agreements or for problems related to a current agreement,
				  contact the Oklahoma Health Care Authority, Provider Enrollment, P.O. Box
				  54015, Oklahoma City, Oklahoma 73154, or call 1-800-522-0114 option 5 toll free
				  or 405-522-6205 for the Oklahoma City area.
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 29 Ok Reg 1073, eff 6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-2.1 - Program Integrity Audits/Reviews

Current through Vol. 41, No. 20, July 1, 2024
(a) This section applies to all contracted
				  providers. The following words and terms, when used in this Section, shall have
				  the following meaning:
(1)
"Contractor/provider"
means any person or organization that has
				  signed a provider agreement with the Oklahoma Health Care Authority
				  (OHCA).
(2)
"Error
				  Rate"
means the percentage of dollars of audited claims found to be
				  billed in error.
(3)
"Extrapolation"
means the methodology of estimating an unknown
				  value by projecting, with a calculated precision (i.e., margin of error), the
				  results of a probability sample to the universe from which the sample was
				  drawn.
(4)
"Probability
				  sample"
means the standard statistical methodology in which a sample is
				  selected based on the theory of probability (a mathematical theory used to
				  study the occurrence of random events).
(5)
"Sample"
means a
				  statistically valid number of claims obtained from the universe of claims
				  audited/reviewed.
(6)
"Universe"
means all paid claims or types of paid claims
				  audited/reviewed during a specified timeframe.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-3 - Group billings

Current through Vol. 41, No. 20, July 1, 2024
(a) A
				  group/corporation is a business entity under which one or more individual
				  providers practice. A group does not require multiple professional providers. A
				  single provider group is a valid group and would be identified by the business
				  entity name. Providers who are in group affiliations and providers who are
				  incorporated under a Federal Employer Identification Number (FEIN) may be paid
				  as a group or corporation. Unless otherwise notified, payments will be issued
				  to a provider as an independent provider, under the personal Social Security
				  Number. To be paid as a group/corporation, or under the Federal Employer
				  Identification Number, providers must contact OHCA to secure a contract for
				  group/corporation billing. It will be the responsibility of the
				  group/corporation to notify the OHCA of changes when a provider leaves or
				  enters the group/corporation affiliation.
(b) A clinic is a facility or distinct part
				  of a facility used for the diagnosis and treatment of outpatients. Clinics are
				  limited to organizations serving specialized treatment requirements or distinct
				  groups. Clinics are specific to specialized provider types as approved by the
				  OHCA. Clinics must have a specialized current contract with the OHCA. Clinic
				  services are covered under
				  317:30-5-575
				  through
				  317:30-5-578.
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 28 Ok Reg 1394, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-3.1

Current through Vol. 41, No. 20, July 1, 2024
Added at 19 Ok Reg
					 325, eff 11-14-01 (emergency); Added at 19 Ok Reg 1067, eff 5-13-02; Amended at
					 19 Ok Reg 2937, eff 7-16-02 (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 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-4 - Electronic fund transfer/direct deposit

Current through Vol. 41, No. 20, July 1, 2024
Providers must accept Medicaid reimbursement via
					 Electronic Fund Transfer /Direct Deposit . These payments are deposited
					 electronically by the State Treasurer to the financial institution the provider
					 designates during the electronic enrollment process. Providers may change the
					 designated financial institution by submitting an update through the electronic
					 enrollment process, subject to OHCA acceptance.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-5 - Assignment and cost sharing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following words and terms, when used in
				  subsection (c) of this Section, shall have the following meaning, unless the
				  context clearly indicates otherwise:
(1)
"Fee-for-service (FFS) contract"
means the provider agreement
				  specified in Oklahoma Administrative Code (OAC)
				  317:30-3-2. This contract is
				  between the Oklahoma Health Care Authority (OHCA) and medical providers which
				  provides for a fee with a specified service involved.
(2)
"Outside of the scope of the
				  services"
means all medical benefits outside the set of services defined
				  at OAC 317:25-7 and the provisions of the SoonerCare Choice contracts in the
				  SoonerCare program.
(3)
"Within the scope of services"
means the set of covered services
				  defined at OAC 317:25-7 and the provisions of the SoonerCare Choice contracts
				  in the SoonerCare program
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-5 - Assignment and cost sharing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following words and terms, when used in
				  subsection (c) of this Section, shall have the following meaning, unless the
				  context clearly indicates otherwise:
(1)
"Fee-for-service (FFS) contract"
means the provider agreement
				  specified in Oklahoma Administrative Code (OAC)
				  317:30-3-2.
				  This contract is the contract between the Oklahoma Health Care Authority (OHCA)
				  and medical providers which provides for a fee with a specified service
				  involved.
(2)
"Outside of the
				  scope of the services"
means all medical benefits outside the set of
				  services defined at OAC 317:25-7 and the provisions of the SoonerCare Choice
				  contracts in the SoonerCare program.
(3)
"Within the scope of
				  services"
means the set of covered services defined at OAC 317:25-7 and
				  the provisions of the SoonerCare Choice contracts in the SoonerCare
				  program.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-5.1 - Usual and customary fees

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Providers are required to indicate their usual and customary charge when
				  submitting claims to SoonerCare. The usual and customary charge is the
				  provider's charge for providing the same service to persons not entitled to
				  SoonerCare benefits. For providers using a sliding fee scale, the usual and
				  customary charge is the one that best represents the most frequently charged
				  amount by the individual provider for the service when provided to
				  non-SoonerCare members. Providers that do not have an established usual and
				  customary charge indicate an amount reasonably related to the provider's cost
				  for providing the service.
(b)
				  Providers may not charge SoonerCare a higher fee than they charge
				  non-SoonerCare patients even if the SoonerCare allowable is greater than the
				  provider's usual and customary fee. Unless otherwise permitted by SoonerCare
				  reimbursement methodology, individual claim payments are limited to the lesser
				  of their usual and customary charge or the SoonerCare allowable.
(c) Providers indicate their usual and
				  customary charge without deducting the co-payment for services that require a
				  member co-payment. When applicable, the co-payment is systematically
				  deducted.
(d) Payment is made based
				  on the amount of the claim submitted, up to the maximum allowable
				  amount.
Added at 24 Ok Reg
					 2059, eff 6-25-07; Amended at 26 Ok Reg 99, eff 10-1-08 (emergency); Amended at
					 26 Ok Reg 1059, eff 5-11-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-6 - Utilization review for physician/hospital services

Current through Vol. 41, No. 20, July 1, 2024
The Surveillance and Utilization Review System (SURS) is
					 used to help identify patterns of inappropriate care and services.
(1) Use of this system enables OHCA to
				  develop a comprehensive profile of any aberrant pattern of practice and reveals
				  suspected instances of fraud or abuse in the SoonerCare Program. Also, the
				  Utilization Review program is a useful tool in detecting the existence of any
				  potential defects in the level of care or service provided under the SoonerCare
				  Program.
(2) OHCA contracts with a
				  Quality Improvement Organization (QIO) to review the length of stay and
				  appropriateness of hospital admissions. Unresolved patterns of non-compliance
				  with medical criteria for admissions, outpatient procedures and length of stay
				  will be referred to OHCA.
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 25 Ok Reg 2633, eff 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-7 - Care assurance validation support review for long term care [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 2557, eff 6-25-01
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-8 - Pre-billing

Current through Vol. 41, No. 20, July 1, 2024
Any covered service performed by a medical provider must be
					 billed only after the service has been provided. No service or procedure may be
					 pre-billed.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-9 - Medical services provided to relatives [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 2565, eff 6-25-01
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-10 - Sales tax

Current through Vol. 41, No. 20, July 1, 2024
Under paragraph (i), Section 1305 exemptions, Article 13,
					 Title 68, O.S. 1981, sales to the State of Oklahoma are exempt from sales tax
					 applicable in the State of Oklahoma.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-11 - Timely filing limitation

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  According to federal regulations, the Authority must require providers to
				  submit all claims no later than 12 months from the date of service. Federal
				  regulations provide no exceptions to this requirement. For dates of service
				  provided on or after July 1, 2015, the timely filing limit, for SoonerCare
				  reimbursement, is 6 months from the date of service. Payment will not be made
				  on claims when more than 6 months have elapsed between the date the service was
				  provided and the date of receipt of the claim by the Fiscal Agent. A denied
				  claim can be considered proof of timely filing.
(b) Claims may be submitted anytime during
				  the month.
(c) To be eligible for
				  payment under SoonerCare, claims for coinsurance and/or deductible must meet
				  the Medicare timely filing requirements. If a claim for payment under Medicare
				  has been filed in a timely manner, the Fiscal Agent must receive a SoonerCare
				  claim relating to the same services within 90 days after the agency or the
				  provider receives notice of the disposition of the Medicare claim.
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 2126, eff
					 6-27-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-11.1 - Resolution of claim payment

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  After the submission of a claim from a provider which had been adjudicated by
				  the Authority, a provider may resubmit the claim under the following rules.
(b) The provider must have
				  submitted the claim initially under the timely filing requirements found at OAC
				  317:30-3-11.
(c) For dates of service provided
				  on or after July 1, 2015, the provider's resubmission of the claim must be
				  received by the Oklahoma Health Care Authority no later than 12 months from the
				  date of service. The only exceptions to the 12 month resubmission claim
				  deadline are the following:
(1)
				  administrative agency corrective action or agency actions taken to resolve a
				  dispute, or
(2) reversal of the
				  eligibility determination, or
(3)
				  investigation for fraud or abuse of the provider, or
(4) court order or hearing decision.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-12 - Credits and adjustments

Current through Vol. 41, No. 20, July 1, 2024
When an overpayment has occurred, the provider should
					 immediately refund the Oklahoma Health Care Authority, by check, to the
					 attention of the Finance Division, P.O. Box 18299, Oklahoma City, OK 73154. In
					 refunding OHCA, be sure to clearly identify the account to which the money is
					 to be applied. The MMIS system has the capability of automatic credits and
					 debits. When an erroneous payment occurs, which results in an overpayment, an
					 automatic recoupment will be made to the provider's account against monies owed
					 to the provider. For more specific information, refer to the Oklahoma Medicaid
					 Provider Billing Manual, Chapter 9: Paid Claim Adjustment
					 Procedures.
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 25 Ok Reg 2633, eff 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-13 - Advance directives

Current through Vol. 41, No. 20, July 1, 2024
(a) Effective
				  December 1, 1991, the Omnibus Budget Reconciliation Act of 1990 (OBRA '90)
				  requires certain Medicaid providers (hospitals, nursing facilities, hospices,
				  home health agencies and non-technical medical care) to:
(1) provide all adult Medicaid patients and
				  residents with written information about their rights under Oklahoma law to
				  make health care decisions, including the right to accept or refuse treatment
				  and the right to execute advance directives;
(2) inform patients and residents about the
				  provider's policy on implementing advance directives. The written information
				  required by law must be given out by hospitals at the time of the individual's
				  admission as an inpatient; by nursing facilities when the individual is
				  admitted as a resident; by a home health agency or non-technical care provider
				  in advance of an adult individual receiving care; and by hospices at the time
				  of initial receipt of hospice care;
(3) document in the patient's medical record
				  whether he/she has signed an advance directive;
(4) not discriminate against an individual
				  based on whether he/she has executed an advance directive; and
(5) provide staff and community education on
				  advance directives.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-15 - Record retention

Current through Vol. 41, No. 20, July 1, 2024
Federal regulations and rules promulgated by the Oklahoma
					 Health Care Authority Board require that the provider retain, for a period of
					 six years, any records necessary to disclose the extent of services the
					 provider, wholly owned supplier, or subcontractor, furnishes to recipients and,
					 upon request, furnish such records to the Secretary of the Department of Health
					 and Human Services. Records in a provider's office must contain adequate
					 documentation of services rendered. Documentation must include the dated
					 provider's signature and credentials. The provider's signature must be
					 handwritten or electronically submitted if the provider and the Oklahoma Health
					 Care Authority have agreed to conduct transactions by electronic means pursuant
					 to the Uniform Electronic Act. Electronic records and electronic signatures
					 must be in accordance with guidelines found at OAC
					 317:30-3-4.1.
					 Where reimbursement is based on units of time, it will be necessary that
					 documentation be placed in the member's record as to the beginning and ending
					 times for the service claimed. All records must be legible. Failure to maintain
					 legible records may result in denial of payment or recoupment of payment for
					 services provided when attempts to obtain transcription of illegible records is
					 unsuccessful or the transcription of illegible records appears to misrepresent
					 the services documented. The provider may, after one year from the date of
					 service(s), microfilm or microfiche the records for the remaining five years,
					 as long as the microfilm or microfiche is of a quality that assures that the
					 records remain legible. Electronic records are acceptable as long as they have
					 a secured signature. Provider (other than individual practitioner) agrees to
					 disclose, upon request, information relating to ownership or control, business
					 transactions and criminal offenses involving any program under Title V of the
					 Child Health Act or Titles, XVIII, XIX, XX, or XXI of the Federal Social
					 Security Act.
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 17 Ok Reg 2368, eff 6-26-00; Amended at 18 Ok Reg 2565, eff
					 6-25-01; Amended at 23 Ok Reg 2461, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-16 - Release of medical records

Current through Vol. 41, No. 20, July 1, 2024
Providers must agree to furnish the medical information
					 necessary for payment of a claim upon request by the Fiscal Agent or OHCA. A
					 release of information for medical records is obtained at the time an
					 application is made for medical assistance. The application specifically
					 states: "For the purpose of determining whether any payment will be made in the
					 behalf of the patient for any medical services, hereafter reported, I do hereby
					 authorize the Authority, or any representative thereof, authorized for the
					 purpose of determining compensability of claims in the patient's behalf, to
					 inspect all hospital and medical records pertaining to such hospitalization or
					 medical services; and I do further authorize the hospital, physician, or other
					 medical provider to release and furnish to the Authority and its
					 representatives, any information shown in such records".
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-17 - Discrimination laws

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority has assured compliance
					 with the regulations of the Department of Health and Human Services, Title 45,
					 Code of Federal Regulations, Part 80 (which implements Public Law 88-352, Civil
					 Rights Act of 1964, Section
					 601
					 ), Part 84 (which implements Public Law 93-112, Rehabilitation Act of 1973,
					 Section 504), Part 90 (which implements Public Law 94-135, Age Discrimination
					 Act of 1975, Section 301), Title 9 of the Education Amendments of 1972; and
					 Executive Orders 11246 and 11375.
(1)
				  These laws and regulations prohibit excluding from participation in, denying
				  the benefits of, or subjecting to discrimination, under any program or activity
				  receiving Federal Financial Assistance any person on the grounds of race,
				  color, sex, national origin, and qualified person on the basis of handicap, or
				  unless program-enabling legislation permits, on the basis of age. Under these
				  requirements, payment cannot be made to vendors providing care and/or services
				  under Federally-assisted programs conducted by the Authority unless such care
				  and service is provided without discrimination on the grounds of race, color,
				  sex, national origin or handicap or without distinction on the basis of age
				  except as legislatively permitted or required.
(2) Written complaints of noncompliance with
				  any of these laws should be made to the Chief Executive Officer of the Oklahoma
				  Health Care Authority, 4345 North Lincoln Boulevard, Oklahoma City, Oklahoma
				  73105, or the Secretary of Health and Human Services, Washington, D.C., or
				  both.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-18 - Criminal penalties

Current through Vol. 41, No. 20, July 1, 2024
Section 1909 of the Social Security Act provides criminal
					 penalties for providers or recipients who make false statements or
					 representations or intentionally conceal facts in order to receive payments or
					 benefits. These penalties apply to kickbacks, bribes or rebates to refer or
					 induce purchase of Medicaid compensable services. The penalties also apply to
					 individuals who knowingly and willfully charge for services to recipients an
					 amount in excess of amounts established by the State.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19

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 1083, eff 12-15-97 (emergency); Amended at 15 Ok
					 Reg 1528, eff 5-11-98; Amended at 23 Ok Reg 771, eff 3-9-06 (emergency);
					 Amended at 23 Ok Reg 2440, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19.1

Current through Vol. 41, No. 20, July 1, 2024
Added at 29 Ok Reg
					 1073, eff 6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19.3 - Denial of application for new or renewed provider enrollment contract

Current through Vol. 41, No. 20, July 1, 2024
(a) The following
				  words and terms, when used in this Section, shall have the following meaning,
				  unless the context clearly indicates otherwise:
(1)
"Affiliates"
means persons
				  having a relationship in which any of them directly or indirectly controls or
				  has the ability to control one or more of the others.
(2)
"Applicant"
means providers
				  and/or persons with a five percent or more direct or indirect ownership
				  interest therein, as well as providers' officers, directors, and managing
				  employees.
(3)
"Conviction"
or
"convicted"
means a person has been
				  convicted of a criminal offense pursuant to
				  42
				  U.S.C. §
												1320a-7(i),
				  or, for civil offenses, has had a judgment of conviction entered against him or
				  her by a Federal, State, or local court, regardless of whether an appeal from
				  the judgment is pending.
(4)
"Person"
means any natural person, partnership, corporation,
				  not-for-profit corporation, professional corporation, or other business
				  entity.
(5)
"Provider"
means any person having or seeking to obtain a valid provider enrollment
				  contract with the Oklahoma Health Care Authority (OHCA) for the purpose of
				  providing services to eligible SoonerCare members and receiving reimbursement
				  therefor.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19.4 - Application fee, provider screening, and applicants subject to a fingerprint-based criminal background check

Current through Vol. 41, No. 20, July 1, 2024
Pursuant to Subpart E of Part 455 of Title 42 of the Code
					 of Federal Regulations (C.F.R.), an enrolling or re-enrolling SoonerCare
					 provider must meet the screening requirements described in this rule and pay an
					 application fee if required in the appendix to this rule. See Appendix A at the
					 end of this chapter.
(1) Application
				  fees. The amount of the application fee is the amount established by the Center
				  for Medicare and Medicaid Services (CMS) in accordance with
				  42
				  United States Code §
											1395cc(j)(2)(C)(i), adjusted
				  for inflation.
(A) Per
				  42 C.F.R. §
												455.460, the application fee shall not apply
				  to the following providers:
(i) Individual
				  physician or non-physician practitioners;
(ii) Providers who have enrolled or
				  re-enrolled in Medicare, and have met the provider screening requirements and
				  paid an application fee to CMS or its designee; and
(iii) Providers who have enrolled or
				  re-enrolled in another state's Medicaid or CHIP program, and have met the
				  provider screening requirements and paid an application fee to the State
				  Medicaid Agency or its designee.
(iv) A provider must submit documentation to
				  support any claim that it meets the exemption(s) described in paragraph
				  (1)(A)(ii) and/or (1)(A)(iii) of this rule.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19.5 - Termination of provider agreements

Current through Vol. 41, No. 20, July 1, 2024
Pursuant to the terms of the Oklahoma Health Care
					 Authority's (OHCA) Standard Provider Agreement, both OHCA and a provider may
					 terminate the agreement without cause on sixty (60) days' notice, or for-cause
					 on thirty (30) days' notice. In addition, OHCA can terminate the agreement
					 immediately in order to protect the health and safety of members, or upon
					 evidence of fraud (including, but not limited to, a credible allegation of
					 fraud as defined by
					 42
					 C.F.R. §
											455.2 ). Conduct that may serve
					 as a basis for a for-cause termination of a provider includes, but is not
					 limited to, any of the following:
(1)
Noncompliance.
The provider is determined not to be in compliance
				  with the enrollment requirements described in Oklahoma Administrative Code
				  (OAC) 317:30-3-2 and
				  317:30-3-19.3, or in the
				  enrollment application applicable for its provider type. OHCA may, but is not
				  required to, request additional documentation from the provider to determine
				  compliance.
(2)
Provider
				  exclusion, debarment, or suspension.
The provider or any owner, managing
				  employee, authorized or delegated official, medical director, supervising
				  physician, or other health care personnel thereof is:
(A) Excluded from the Medicare, Medicaid, or
				  any other Federal health care program, as defined in
				  42
				  C.F.R §
												1001.2; or
(B) Debarred, suspended, or otherwise
				  excluded from participating in any other Federal procurement or nonprocurement
				  program or activity.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-19.6 - Complaints related to the Defunding Statutory Rape Cover-up Act

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				  with Title 56 of the Oklahoma Statutes (O.S.) §
										1007.4, the Oklahoma Health Care
				  Authority (OHCA) shall investigate complaints made pursuant to the Defunding
				  Statutory Rape Cover-up Act that are submitted in writing to OHCA's Legal
				  Division, and that include:
(1) The name and
				  contact information of the person submitting the complaint;
(2) The name of the health care provider
				  and/or affiliate, as that term is defined by 56 O.S. § 1007.1, who is
				  alleged:
(A) To have been found by a court of
				  law to have failed to report statutory rape; or
(B) To have failed to report statutory rape
				  where the statutory rape resulted in a conviction against the assailant;
(3) The name of the
				  SoonerCare member who allegedly was the victim of statutory rape (if the member
				  is an adult), or of the member's parent(s) or legal guardian (if the member is
				  a minor); and
(4) A short summary
				  of any other relevant information.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-20 - Claim inquiry procedures (excluding nursing homes and hospitals)

Current through Vol. 41, No. 20, July 1, 2024
A medical provider may request a review of the amount paid
					 or the non-payment of medical services provided to an eligible member. If the
					 medical provider does not agree with the adjudication of the original claim,
					 he/she may submit an electronic request for review on the Oklahoma Health Care
					 Authority (OHCA) provider portal in accordance with the instructions in the
					 Provider Billing and Procedures Manual, available on OHCA's website,
www.okhca.org
. Documentation, including but
					 not limited to, supporting medical documentation and/or proof of timely filing
					 as outlined in Oklahoma Administrative Code (OAC)
					 317:30-3-11,
					 must be included with each submission.
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 3585, eff 7-16-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 3784, eff 7-1-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 23 Ok Reg 771, eff 3-9-06
					 (emergency); Amended at 23 Ok Reg 2440, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-20.1 - Pharmacy grievance procedures and processes [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 21 Ok Reg
					 2459, eff 7-11-05; Revoked at 28 Ok Reg 1393, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-21 - Appeals procedures for nursing facilities

Current through Vol. 41, No. 20, July 1, 2024
Appeal procedures for denial, failure to renew, or
					 termination of a nursing facility agreement are described at OAC
					 317:30-5-124(h).
					 The Oklahoma State Department of Health, by agreement, continues to be
					 responsible for hearings for licensure and certification as the survey agency.
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 3585, eff 7-16-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 3784, eff 7-1-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 23 Ok Reg 771, eff 3-9-06
					 (emergency); Amended at 23 Ok Reg 2440, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-22 - Hospital reimbursement rate appeals [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 3585, eff 7-16-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Revoked at 15 Ok Reg 3784, eff 7-1-98 (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 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-23 - Reconsideration request

Current through Vol. 41, No. 20, July 1, 2024
If the QIO, upon their initial review determines the
					 admission should be denied, a notice is issued to the facility and the
					 attending physician advising them of the decision and advising them that a
					 reconsideration request may be submitted in accordance with the Medicare time
					 frame. Additional information submitted with the reconsideration request will
					 be reviewed by the QIO who utilizes an independent physician advisor. If the
					 denial decision is upheld through this reconsideration review of additional
					 information, OHCA is informed. At that point OHCA sends a letter to the
					 hospital and physician requesting a refund of the SoonerCare payment previously
					 made on the denied admission. The member is not responsible for denied
					 charges.
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 25 Ok Reg 2633, eff 7-25-08