Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 1 - PHYSICIANS › Section 317:30-5-2 - General coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Payment for adults is made to physicians for medical and
				  surgical services within the scope of the Oklahoma Health Care Authority's
				  (OHCA) SoonerCare program, provided the services are reasonable and necessary
				  for the diagnosis and treatment of illness or injury, or to improve the
				  functioning of a malformed body member. Coverage of certain services must be
				  based on a determination made by the OHCA's medical consultant in individual
				  circumstances.
(1) Coverage includes, but is
				  not limited to, the following medically necessary services:
(A) Inpatient hospital visits for all
				  SoonerCare covered stays. All inpatient services are subject to post-payment
				  review by the OHCA, or its designated agent.
(B) Inpatient psychotherapy by a physician.
(C) Inpatient psychological
				  testing by a physician.
(D) One (1)
				  inpatient visit per day, per physician.
(E) Certain surgical procedures performed in
				  a Medicare certified free-standing ambulatory surgery center (ASC) or a
				  Medicare certified hospital that offers outpatient surgical services.
(F) Therapeutic radiology or
				  chemotherapy on an outpatient basis without limitation to the number of
				  treatments per month for members with proven malignancies.
(G) Physician services on an outpatient basis
				  include:
(i) A maximum of four (4) visits per
				  member per month, including primary care or specialty, with the exception of
				  SoonerCare Choice members.
(ii)
				  Additional visits are allowed per month for treatment related to emergency
				  medical conditions and family planning services.
(H) Direct physician services in a nursing
				  facility.
(i) A maximum of two (2) nursing
				  facility visits per month are allowed; and if the visit (s) is for psychiatric
				  services, it must be provided by a psychiatrist or a physician with appropriate
				  behavioral health training.
(ii) To
				  receive payment for a second nursing facility visit in a month denied by
				  Medicare for a Medicare/SoonerCare member, attach the explanation of Medicare
				  benefits (EOMB) showing denial and mark "carrier denied coverage."
(I) Diagnostic x-ray and
				  laboratory services.
(J)
				  Mammography screening and additional follow-up mammograms as per current
				  guidelines.
(K) Obstetrical care.
(L) Pacemakers and prostheses
				  inserted during the course of a surgical procedure.
(M) Prior authorized examinations for the
				  purpose of determining medical eligibility for programs administered by OHCA. A
				  copy of the authorization, Oklahoma Department of Human Services (OKDHS) form
				  08MA016E, Authorization for Examination and Billing, must accompany the claim.
(N) If a physician renders direct
				  care to a member on the same day as a dialysis treatment, payment is allowed
				  for a separately identifiable service unrelated to the dialysis.
(O) Family planning includes sterilization
				  procedures for legally competent members twenty-one (21) years of age and over
				  who voluntarily request such a procedure and execute the federally mandated
				  consent form with his/her physician. A copy of the consent form must be
				  attached to the claim form. Separate payment is allowed for the insertion
				  and/or implantation of contraceptive devices during an office visit. Certain
				  family planning products may be obtained through the Vendor Drug Program.
				  Reversal of sterilization procedures for the purposes of conception is not
				  allowed. Reversal of sterilization procedures are allowed when medically
				  indicated and substantiating documentation is attached to the claim.
(P) Genetic counseling.
(Q) Laboratory testing.
(R) Payment for ultrasounds for pregnant
				  women as specified in Oklahoma Administrative Code (OAC)
				  317:30-5-22.
(S) Payment to the attending
				  physician in a teaching medical facility for compensable services when the
				  physician signs as claimant and renders personal and identifiable services to
				  the member in conformity with federal regulations.
(T) Payment to the attending physician for
				  the services of a currently Oklahoma licensed physician in training when the
				  following conditions are met:
(i) Attending
				  physician performs chart review and signs off on the billed encounter;
(ii) Attending physician is
				  present in the clinic/or hospital setting and available for consultation; and
(iii) Documentation of written
				  policy and applicable training of physicians in the training program regarding
				  when to seek the consultation of the attending physician.
(U) Payment for services rendered by medical
				  residents in an outpatient academic setting when the following conditions are
				  met:
(i) The resident has obtained a medical
				  license or a special license for training from the appropriate regulatory state
				  medical board; and
(ii) Has the
				  appropriate contract on file with the OHCA to render services within the scope
				  of their licensure.
(V)
				  The payment to a physician for medically directing the services of a certified
				  registered nurse anesthetist (CRNA) or for the direct supervision of the
				  services of an anesthesiologist assistant (AA) is limited. The maximum
				  allowable fee for the services of both providers combined is limited to the
				  maximum allowable had the service been performed solely by the
				  anesthesiologist.
(W) Screening and
				  follow up pap smears as per current guidelines.
(X) Medically necessary organ and tissue
				  transplantation services for children and adults are covered services based
				  upon the conditions listed in (i)-(v) of this subparagraph:
(i) All transplantation services, except
				  kidney and cornea, must be prior authorized;
(ii) All transplant procedures are reviewed
				  and prior authorization is based upon appropriate medical criteria;
(iii) All organ transplants must be performed
				  at a Medicare-approved transplantation center;
(iv) Procedures considered experimental or
				  investigational are not covered. For more information regarding experimental or
				  investigational including clinical trials, see OAC 317:30-3-57.1; and
(v) Donor search and procurement
				  services are covered for transplants consistent with the methods used by the
				  Medicare program for organ acquisition costs.
(Y) Donor expenses incurred for complications
				  are covered only if they are directly and immediately attributable to the
				  donation procedure. Donor expenses that occur after the ninety (90) day global
				  reimbursement period must be submitted to the OHCA for review.
(Z) Total parenteral nutritional (TPN)
				  therapy for identified diagnoses and when prior authorized.
(AA) Ventilator equipment.
(BB) Home dialysis equipment and supplies.
(CC) Ambulatory services for
				  treatment of members with tuberculosis (TB). This includes, but is not limited
				  to, physician visits, outpatient hospital services, rural health clinic visits
				  and prescriptions. Drugs prescribed for the treatment of TB beyond the
				  prescriptions covered under SoonerCare require prior authorization by the
				  University of Oklahoma College of Pharmacy Help Desk using form "Petition for
				  TB Related Therapy." Ambulatory services to members infected with TB are not
				  limited to the scope of the SoonerCare program, but require prior authorization
				  when the scope is exceeded.
(DD)
				  Smoking and tobacco use cessation counseling for treatment of members using
				  tobacco.
(i) Smoking and tobacco use
				  cessation counseling consists of the 5As:
(I)
				  Asking the member to describe their smoking use;
(II) Advising the member to quit;
(III) Assessing the willingness of the member
				  to quit;
(IV) Assisting the member
				  with referrals and plans to quit; and
(V) Arranging for follow-up.
(ii) Up to eight (8) sessions are
				  covered per year per individual.
(iii) Smoking and tobacco use cessation
				  counseling is a covered service when performed by physicians, physician
				  assistants (PA), advanced registered nurse practitioners (ARNP), certified
				  nurse midwives (CNM), dentists, Oklahoma State Health Department (OSDH) and
				  Federally Qualified Health Center (FQHC) nursing staff, and maternal/child
				  health licensed clinical social worker trained as a certified tobacco treatment
				  specialist (CTTS). It is reimbursed in addition to any other appropriate global
				  payments for obstetrical care, primary care provider (PCP) care coordination
				  payments, evaluation and management codes, or other appropriate services
				  rendered. It must be a significant, separately identifiable service, unique
				  from any other service provided on the same day.
(iv) Chart documentation must include a
				  separate note that addresses the 5A's and office note signature along with the
				  member specific information addressed in the five (5) steps and the time spent
				  by the practitioner performing the counseling. Anything under three (3) minutes
				  is considered part of a routine visit and not separately billable.
(EE) Immunizations as specified by
				  the Advisory Committee on Immunization Practices (ACIP) guidelines.
(FF) Genetic testing and other molecular
				  pathology services are covered when medically necessary. Genetic testing may be
				  considered medically necessary when the following conditions are met:
(i) The member displays clinical features of
				  a suspected genetic condition, is at direct risk of inheriting the genetic
				  condition in question (e.g., a causative familial variant has been identified)
				  or has been diagnosed with a condition where identification of specific genetic
				  changes will impact treatment or management; and
(ii) Clinical studies published in
				  peer-reviewed literature have established strong evidence that the result of
				  the test will positively impact the clinical decision-making or clinical
				  outcome for the member; and
(iii)
				  The testing method is proven to be scientifically valid for the identification
				  of a specific genetically-linked inheritable disease or clinically important
				  molecular marker; and
(iv) A
				  medical geneticist, physician, or licensed genetic counselor provides
				  documentation that supports the recommendation for testing based on a review of
				  risk factors, clinical scenario, and family history.