Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-59 - General program exclusions - adults

Current through Vol. 41, No. 20, July 1, 2024
The following are excluded from SoonerCare coverage for
					 adults:
(1) Inpatient admission for
				  diagnostic studies that could be performed on an outpatient basis.
(2) Services or any expense incurred for
				  cosmetic surgery.
(3) Services of
				  two (2) physicians for the same type of service to the same member on the same
				  day, except when supplemental skills are required and different specialties are
				  involved.
(4) Refractions and
				  visual aids.
(5) Pre-operative care
				  within twenty-four (24) hours of the day of admission for surgery and routine
				  post-operative care as defined under the global surgery guidelines promulgated
				  by Current Procedural Terminology (CPT) and the Centers for Medicare and
				  Medicaid Services (CMS).
(6)
				  Sterilization of members who are under twenty-one (21) years of age, mentally
				  incompetent, or institutionalized or reversal of sterilization procedures for
				  the purposes of conception.
(7)
				  Non-therapeutic hysterectomies.
(8)
				  Induced abortions, except when certified in writing by a physician that the
				  abortion was necessary due to a physical disorder, injury or illness, including
				  a life-endangering physical condition caused by or arising from the pregnancy
				  itself, that would place the woman in danger of death unless an abortion is
				  performed, or that the pregnancy is the result of an act of rape or
				  incest.
(9) Medical services
				  considered experimental or investigational. For more information regarding
				  coverage of clinical trials, see Oklahoma Administrative Code (OAC)
				  317:30-3-57.1.
(10) Services of a
				  certified surgical assistant.
(11)
				  Services of a chiropractor. Payment is made for chiropractor services on
				  crossover claims for coinsurance and/or deductible only.
(12) Services of an independent licensed
				  physical therapist and/or licensed physical therapist assistant. Per OAC
				  317:30-5-291.
(13) Services of an independent licensed
				  occupational therapist and/or occupational therapist assistant. Per OAC
				  317:30-5-296.
(14) Services of a psychologist.
(15) Services of an independent licensed
				  speech-language pathologist, speech-language pathology assistant (SLPA), and/or
				  speech-language clinical fellow. Per OAC
				  317:30-5-675.
(16) Payment for more than four (4)
				  outpatient visits per month (home or office) per member, except those visits in
				  connection with family planning or related to emergency medical
				  conditions.
(17) Payment for more
				  than two (2) long-term care facility visits per month.
(18) More than one (1) inpatient visit per
				  day per physician.
(19) Payment for
				  removal of benign skin lesions.
(20) Physician services which are
				  administrative in nature and not a direct service to the member including such
				  items as quality assurance, utilization review, treatment staffing, tumor board
				  review or multidisciplinary opinion, dictation, and similar
				  functions.
(21) Charges for
				  completion of insurance forms, abstracts, narrative reports or telephone
				  calls.
(22) Payment for the
				  services of social workers, licensed family counselors, registered nurses or
				  other ancillary staff, except as specifically set out in the Oklahoma Health
				  Care Authority (OHCA) rules.
(23)
				  Mileage.
(24) A routine hospital
				  visit on the date of discharge unless the member expired.
(25) Direct payment to perfusionist as this
				  is considered part of the hospital reimbursement.
(26) Fertility treatment.
(27) Payment to the same physician for both
				  an outpatient visit and admission to hospital on the same date.
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 14 Ok Reg 3077, eff 7-1-97 (emergency); Amended at 15 Ok
					 Reg 1528, eff 5-11-98; Amended at 15 Ok Reg 4194, eff 7-20-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3413, eff 7-1-99
					 (emergency); Amended at 17 Ok Reg 2373, eff 6-26-00; Amended at 17 Ok Reg 3469,
					 eff 8-1-00 (emergency); Amended at 18 Ok Reg 2566, eff 6-25-01; Amended at 20
					 Ok Reg 1924, eff 6-26-03; Amended at 21 Ok Reg 501, eff 1-1-04 (emergency);
					 Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 23 Ok Reg 239, eff 10-3-05
					 (emergency); Amended at 23 Ok Reg 2487, eff 6-25-06; Amended at 24 Ok Reg 141,
					 eff 10-8-16 (emergency); Amended at 24 Ok Reg 890, eff 5-11-07; Amended at 25
					 Ok Reg 112, eff 10-1-07 (emergency); Amended at 25 Ok Reg 1192, eff 5-25-08;
					 Amended at 27 Ok Reg 294, eff 11-3-09 (emergency); Amended at 27 Ok Reg 1439,
					 eff 6-11-10; Amended at 28 Ok Reg 1412, eff
					 6-25-11