Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 83 - THERAPEUTIC FOSTER CARE › Section 317:30-5-741 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Behavioral health services in TFC settings are not covered
				  for adults.
(b)
Children.
Behavioral health services are allowed in TFC settings
				  for children under twenty-one (21) as medically necessary. Members receiving
				  services in this setting have moderate behavioral and emotional health needs,
				  and may also present secondary physical, developmental, intellectual, and/or
				  social disorder that is supported alongside the mental health needs. The
				  designated members must continually meet medical necessity criteria to be
				  eligible for coverage in this setting. Requests for behavioral health services
				  in a TFC setting must be prior authorized and may be approved up to a maximum
				  of six (6) month extensions.
(c)
Medical necessity criteria.
In order to satisfy medical necessity
				  criteria, all of the following conditions must be met:
(1) The member must have a diagnosis from the
				  Diagnostic and Statistical Manual of Mental Disorders (DSM-V), with the
				  exception of V codes and adjustment disorders, with a detailed description of
				  the symptoms supporting the diagnosis. Members with a provisional diagnosis may
				  receive TFC services for a maximum of thirty (30) days.
(2) An assessment must be completed by a
				  licensed behavioral health professional (LBHP) or licensure candidate as
				  defined in Oklahoma Administrative Code (OAC)
				  317:30-5-240.3(a) and
				  (b) within the thirty (30) day provisional
				  period described above, that confirms a diagnosis from the DSM-V with the
				  exception of V codes and adjustments disorders, and that includes a detailed
				  description of the symptoms supporting the diagnosis to continue treatment in a
				  TFC setting.
(3) Conditions are
				  directly attributed to moderate behavioral and emotional needs as the primary
				  need for professional attention.
(4) The current disabling symptoms could not
				  have been/have not been manageable in a less intensive treatment program, or
				  the level of care is warranted in order to reduce the risk of regression of
				  symptoms and/or sustain the gains made at a higher level of care.
(5) Evidence that the members' needs prohibit
				  full integration in a family/home setting without the availability of
				  twenty-four (24) hour crisis response/behavior management and clinical
				  interventions from professional staff, preventing the member from living in a
				  traditional family home.
(6) The
				  member is medically stable and not actively suicidal or homicidal and not in
				  need of substance abuse detoxification services.
(7) The legal guardian [Oklahoma Department
				  of Human Services (OKDHS)/ Oklahoma Office of Juvenile Affairs (OJA) if custody
				  member] or parent of the member agrees to actively participate in the member's
				  treatment needs and planning.