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 1 - PHYSICIANS › Section 317:30-5-4 - Procedure and diagnosis coding

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The Authority uses the Health Care Financing Administration Common Procedure
				  Coding System (HCPCS). This system is a five digit coding system using numbers
				  and letters. Modifiers are used to further identify services. There are two
				  sets of codes in the HCPCS system which are maintained by different
				  organizations. First are the CPT codes, established and maintained by the
				  American Medical Association. Second, are the second level HCPCS codes assigned
				  and maintained by the Federal Health Care Financing Administration, the
				  American Dental Association, etc. These codes are common to all Medicare
				  Carriers.
(b) The coding process in
				  the CPT includes a description of the various levels of services and a guide to
				  selecting the codes which appropriately describe the level of services
				  provided. Normally a physician will perform office, hospital, nursing home and
				  emergency room visits which include the complete range of levels of service
				  from brief to comprehensive. Physicians who routinely bill only for higher
				  levels of care may appear on utilization reports and will be reviewed and/or
				  investigated to determine if the service rendered matches the level of service
				  claimed.
(c) The Authority accepts
				  the International Classification of Diseases diagnosis coding currently used by
				  the Centers for Medicare and Medicaid Services.
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 3627,
						eff 7-16-96 (emergency) ; Amended at 14 Ok Reg 1780, eff 5-27-97 ; Amended at
						16 Ok Reg 151, eff 10-14-98 (emergency) ; Amended at 16 Ok Reg 1429, eff
						5-27-99 ; Amended at 17 Ok Reg 706, eff 1-10-00 (emergency) ; Amended at 17 Ok
						Reg 2368, eff 6-26-00 ; Amended at 18 Ok Reg 109, eff 10-7-00 (emergency) ;
						Amended at 18 Ok Reg 2557, eff 6-25-01 ; Amended at 19 Ok Reg 2134, eff 6-27-02
						; Amended at 30 Ok Reg 1169, eff 7-1-13
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 317:30-5-5 - Diagnosis Codes [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 19 Ok Reg 2134, eff 6-27-02
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 317:30-5-6 - Abortions

Current through Vol. 41, No. 20, July 1, 2024
(a) Payment is made
				  only for abortions in those instances where the abortion is 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, as
				  certified by a physician, place the woman in danger of death unless an abortion
				  is performed, or where the pregnancy is the result of an act of rape or incest.
				  Medicaid coverage for abortions to terminate pregnancies that are the result of
				  rape or incest will only be provided as long as Congress considers abortions in
				  cases of rape or incest to be medically necessary services and federal
				  financial participation is available specifically for these services.
(1) For abortions 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, the physician must complete
				  the Certification for Medicaid Funded Abortion and certify in writing that the
				  abortion is being performed 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. The patient's name and address must be included in the
				  certification and the certification must be signed and dated by the physician.
				  The certification must be attached to the claim.
(2) For abortions in cases of rape or incest,
				  there are two requirements for the payment of a claim. First, the physician
				  must fully complete the Certification for Medicaid Funded Abortion. Second, the
				  patient must have made a police report or counselor's report of the rape or
				  incest. In cases where an official report of the rape or incest is not
				  available, the physician must certify in writing and provide documentation that
				  in his or her professional opinion, the patient was unable, for physical or
				  psychological reasons, to comply with the requirement. The statement explains
				  the reason the rape or incest was not reported. The patient's name and address
				  must be included in the certification and the certification must be signed and
				  dated by the physicianand the patient . In cases where a physician provides
				  certification and documentation of a patient's inability to file a report, the
				  Authority will perform a prepayment review of all records to ensure there is
				  sufficient documentation to support the physician's certification.
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 317:30-5-7 - Anesthesia

Current through Vol. 41, No. 20, July 1, 2024
(a)
Procedure
				  codes.
Anesthesia codes from the Physicians' Current Procedural
				  Terminology should be used. Payment is made only for the major procedure during
				  an operative session.
(b)
Modifiers.
All anesthesia procedure codes must have a modifier.
				  Without the modifier, the claim will be denied.
(c)
Qualifying circumstances.
Certain codes in the Medicine section of the CPT are used to identify
				  extraordinary anesthesia services. The appropriate modifiers should be added to
				  these codes. Additional payment can be made for extremes of age, total body
				  hypothermia, and controlled hypertension.
(d)
Hypothermia.
Hypothermia
				  total body or regional is not covered unless medical necessity is documented
				  and approved through review by the Authority's Medical Consultants.
(e)
Anesthesia with Blood Gas
				  Analysis.
Blood gas analysis is part of anesthesia service. Payment for
				  anesthesia includes payment for blood gas analysis.
(f)
Steroid injections.
Steroid
				  injections administered by an anesthesiologist are covered as nerve block. The
				  appropriate CPT procedure code is used to bill services.
(g)
Local anesthesia.
If local
				  anesthesia is administered by attending surgeon, payment is included in the
				  global surgery fee, except for spinal or epidural anesthesia in conjunction
				  with childbirth.
(h)
Stand by
				  anesthesia.
This is not covered unless the physician is actually in the
				  operating room administering medication, etc. If this is indicated, claim will
				  be processed as if anesthesia was given. Use appropriate anesthesia
				  code.
(i)
Other qualifying
				  circumstances.
All other qualifying circumstances, i.e., physical
				  status, emergency, etc. have been structured into the total allowable for the
				  procedure.
(j)
Central venous
				  catheter and anesthesia.
Payment for placement of central venous
				  catheter, injection of anesthesia substance or similar procedures will be made
				  only when the procedure is distinctly separate from the anesthesia
				  procedure.
(k)
Pain
				  management.
Pain management procedures performed during the anesthesia
				  session will be covered when medically necessary to adequately control
				  anticipated post-operative pain.
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 708, eff 1-10-00 (emergency); Amended at 17 Ok
					 Reg 1204, eff 5-11-00; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 20 Ok
					 Reg 1924, eff 6-26-03; Amended at 29 Ok Reg 1084, eff
					 6-25-12
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 317:30-5-9 - Medical services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Use of
				  medical modifiers.
The physicians' Current Procedural Terminology (CPT)
				  and the second level Healthcare Common Procedure Coding System (HCPCS) provide
				  for 2-digit medical modifiers to further describe medical services. Modifiers
				  are used when appropriate.
(b)
Covered office services.
(1)
				  Payment is made for four(4) office visits (or home) per month per member, for
				  adults [over age twenty-one (21)] , regardless of the number of physicians
				  involved. Additional visits per month are allowed for services related to
				  emergency medical conditions.
(2)
				  Visits for the purpose of family planning are excluded from the four(4) per
				  month limitation.
(3) Payment is
				  allowed for the insertion and/or implantation of contraceptive devices in
				  addition to the office visit.
(4)
				  Separate payment will be made for the following supplies when furnished during
				  a physician's office visit.
(A) Casting
				  materials;
(B) Dressing for burns;
(C) Contraceptive devices; and
(D) IV fluids.
(5) Medically necessary office lab
				  and X-rays are covered.
(6) Hearing
				  exams by physician for members between the ages of twenty one (21) and sixty
				  five (65) are covered only as a diagnostic exam to determine type, nature and
				  extent of hearing loss.
(7) Hearing
				  aid evaluations are covered for members under twenty one (21) years of age.
(8) IPPB (Intermittent Positive
				  Pressure Breathing) is covered when performed in physician's office.
(9) Payment is made for an office visit in
				  addition to allergy testing.
(10)
				  Separate payment is made for antigen.
(11) Eye exams are covered for members
				  between ages twenty one (21) and sixty five (65) for medical diagnosis only.
(12) If a physician personally
				  sees a member on the same day as a dialysis treatment, payment can be made for
				  a separately identifiable service unrelated to the dialysis.
(13) Separate payment is made for the
				  following specimen collections:
(A)
				  Catheterization for collection of specimen; and
(B) Routine venipuncture .
(14) The Professional Component
				  for electrocardiograms, electroencephalograms, electromyograms, and similar
				  procedures are covered on an inpatient basis as long as the interpretation is
				  not performed by the attending physician.
(15) Cast removal is covered only when the
				  cast is removed by a physician other than the one who applied the cast.
(16) Payment may be made for
				  medication-assisted treatment (MAT) medications prescribed and/or administered
				  by a physician.
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 317:30-5-10 - Ophthalmology services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Covered
				  services for adults.
(1) Payment can be
				  made for medical services that are reasonable and necessary for the diagnosis
				  and treatment of illness or injury up to the patient's maximum number of
				  allowed office visits per month.
(2) There is no provision for routine eye
				  exams, examinations for the purpose of prescribing glasses or visual aids,
				  determination of refractive state or treatment of refractive errors, or
				  purchase of lenses, frames, or visual aids. Payment is made for treatment of
				  medical or surgical conditions which affect the eyes. Providers must notify
				  members in writing of services not covered by SoonerCare prior to providing
				  those services. Determination of refractive state or other non-covered service
				  may be billed to the patient if properly notified.
(3) The global surgery fee allowance includes
				  preoperative evaluation and management services rendered the day before or the
				  day of surgery, the surgical procedure, and routine postoperative period.
				  Co-management for cataract surgery is filed using appropriate CPT codes,
				  modifiers and guidelines. If an optometrist has agreed to provide postoperative
				  care, the optometrist's information must be in the referring provider's section
				  of the claim.
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 317:30-5-11 - Psychiatric services

Current through Vol. 41, No. 20, July 1, 2024
(a) Payment is made
				  for procedure codes listed in the psychiatry section of the most recent edition
				  of the American Medical Association Current Procedural Terminology (CPT)
				  codebook. The codes in this service range are accepted services within the
				  SoonerCare program for children and adults with the following exceptions:
(1) Psychiatric evaluation of hospital
				  records, other psychiatric reports, psychometric and/or projective tests, and
				  other accumulated data for medical diagnostic purposes.
(2) Interpretation or explanation of results
				  of psychiatric, other medical examinations and procedures, or other accumulated
				  data to family or other responsible persons, or advising them how to assist the
				  patient.
(3) Preparation of report
				  of patient's psychiatric status, history, treatment, or progress (other than
				  for legal or consultative purposes) for other physicians, agencies, or
				  insurance carriers.
(4) Unlisted
				  psychiatric service or procedure.
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 317:30-5-12 - Family planning

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Payment is made for the following family planning
				  services:
(1) physical examination to
				  determine the general health of the member and most suitable method of
				  contraception;
(2) complete general
				  history of the member and pertinent history of immediate family
				  members;
(3) laboratory services
				  for the determination of pregnancy, detection of certain sexually transmitted
				  infections and detection of cancerous or pre-cancerous conditions of the
				  reproductive anatomy;
(4) education
				  and counseling regarding issues related to reproduction and
				  contraception;
(5) annual supply of
				  chosen contraceptive;
(6) insertion
				  and removal of contraceptive devices;
(7) vasectomy and Tubal Ligation procedures;
				  and
(8) additional visits for
				  members experiencing difficulty with a particular contraceptive method or
				  having concerns related to their reproductive health.
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 317:30-5-13 - Rape and abuse exams

Current through Vol. 41, No. 20, July 1, 2024
When a rape/abuse exam is performed on a child with
					 SoonerCare benefits, a claim is filed with the fiscal agent. Payment is made
					 for the rape/abuse exam and medically necessary procedures as per recognized
					 coding guidelines.
(1) Supplies used
				  during an exam for rape or abuse may be billed. Appropriate HCPCS and diagnosis
				  codes are used.
(2) If the child is
				  in custody as reported by the Oklahoma Department of Human Services but does
				  not have SoonerCare benefits, or the child is not in custody and the parents
				  are unable or unwilling to assume payment responsibility, the social worker
				  obtains from the physician a completed OKDHS form 10AD012, Claim Form. The
				  10AD012 form is routed according to procedures established by the Oklahoma
				  Department of Human Services, Division of Children and Family
				  Services.
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; Amended at 24 Ok Reg 78, eff
					 8-2-06 (emergency); Amended at 24 Ok Reg 902, eff
					 5-11-07
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 317:30-5-14 - Injections

Current through Vol. 41, No. 20, July 1, 2024
(a) Coverage for
				  injections is limited to those categories of drugs included in the vendor drug
				  program for SoonerCare. SoonerCare payment is not available for injectable
				  drugs whose manufacturers have not entered into a drug rebate agreement with
				  the Centers for Medicare and Medicaid Services (CMS). OHCA administers and
				  maintains an open formulary subject to the provisions of Title 42, United
				  States Code (U.S.C.), Section 1396r-8 . The OHCA covers a drug that has been
				  approved by the Food and Drug Administration (FDA) subject to the exclusions
				  and limitations provided in OAC
				  317:30-5-72.1.
(1)
Immunizations for children.
An administration fee will be paid for vaccines administered by providers
				  participating in the Vaccines for Children Program. For vaccines administered
				  as part of the Vaccines for Children Program, only one administration fee is
				  permitted per vaccine, regardless of the number of vaccine/toxoid components in
				  the vaccine. Payment will not be made for vaccines covered by the Vaccines for
				  Children Program. When the vaccine is not included in the program, the
				  administration fee is separately payable.
(2)
Immunizations for adults.
Coverage for adults is provided as per the Advisory Committee on Immunization
				  Practices (ACIP) guidelines. A separate payment will be made for the
				  administration of a vaccine. Only one administration fee per vaccine is
				  permitted, regardless of the number of vaccine/toxoid components in the
				  vaccine.
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 317:30-5-14.1 - Allergy services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Allergy
				  testing.
Allergy testing is the process of identifying allergen(s) that
				  may cause an allergic or anaphylactic reaction and the degree of the reaction.
				  By identifying the allergen(s), the member can avoid exposures and the allergic
				  reaction can be managed appropriately. Treatment options for allergies are
				  avoidance of the allergen(s), pharmacological therapy, and/or immunotherapy.
				  Oklahoma Health Care Authority (OHCA) may consider allergy testing medically
				  necessary when a complete medical, immunological history, and physical
				  examination is performed and indicates symptoms are suggestive of a chronic
				  allergy. Allergy testing may also be determined medically necessary if
				  diagnosis indicates an allergy and simple medical treatment and avoidance of
				  the allergen(s) were tried and showed inadequate response.
(1)
Coverage.
OHCA will provide
				  reimbursement for allergy testing when the following conditions are met:
(A) Testing is done in a hospital or
				  providers office under direct supervision of an eligible provider;
(B) The diagnostic testing is based on the
				  member's immunologic history and physical examination, which document that the
				  antigen(s) being used for testing have a reasonable probability of exposure in
				  the members environment;
(C) The
				  member has significant life-threatening symptomatology or a chronic allergic
				  state (e.g., asthma) which has not responded to conservative measures;
(D) The member's records document
				  the need for allergy testing and the justification for the number of tests
				  performed;
(E) The complete report
				  of the test results, as well as controls, will be kept as part of the medical
				  record; and
(F) The member is
				  observed for a minimum of twenty (20) minutes following allergy testing to
				  monitor for signs of allergic or anaphylactic reactions.
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 317:30-5-15 - Chemotherapy injections

Current through Vol. 41, No. 20, July 1, 2024
(a)
Outpatient.
(1) Outpatient
				  chemotherapy is compensable only when a malignancy is indicated or for the
				  diagnosis of Acquired Immune Deficiency Syndrome (AIDS). Outpatient
				  chemotherapy treatments are unlimited. Outpatient visits in connection with
				  chemotherapy are limited to four per month.
(2) Payment for administration of
				  chemotherapy medication is made under the appropriate National Drug Code (NDC)
				  and HCPCS code as stated in OAC
				  317:30-5-14(b).
				  Payment is made separately for office visit and administration under the
				  appropriate CPT code.
(3) When
				  injections exceed listed amount of medication, show units times appropriate
				  quantity, i.e., injection code for 100 mgm but administering 300, used 100 mgm
				  times 3 units.
(4) Glucose - fed
				  through IV in connection with chemotherapy administered in the office is
				  covered under the appropriate NDC and HCPCS code.
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 317:30-5-16 - Miscellaneous injections [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 2315, eff 4-10-96 (emergency); Amended at 13 Ok
					 Reg 3627, eff 7-16-96 (emergency); Amended at 14 Ok Reg 1780, eff 5-27-97;
					 Revoked at 18 Ok Reg 109, eff 6-1-00 (emergency); Revoked at 18 Ok Reg 1130,
					 eff 5-11-01
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 317:30-5-17 - Authorized examinations - eligibility determinations

Current through Vol. 41, No. 20, July 1, 2024
When an examination is to be made for the purpose of
					 determining original or continuing eligibility, it is necessary that DHS Form
					 ABCDM-16, Authorization for Examination and Billing, be secured from the county
					 office of the Department of Human Services. Report of such examination must be
					 submitted on DHS Form ABCDM-80. DHS Form ABCDM-16 must be attached to the
					 claim. If a UA is indicated, payment will be made separately at the current
					 allowable rate.
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
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 317:30-5-18 - Elective sterilizations

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Payment is made for elective sterilizations performed in behalf of eligible
				  individuals if all of the following circumstances are met:
(1) The patient must be at least 21 years of
				  age at the time the consent form is signed;
(2) The patient must be mentally competent,
				  and not presently institutionalized;
(3) A properly completed federally mandated
				  consent for sterilization form is attached to the claim; and
(4) The form is signed and dated at least 30
				  days, but not more than 180 days prior to surgery.
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 317:30-5-19 - Hysterectomies

Current through Vol. 41, No. 20, July 1, 2024
(a) A hysterectomy
				  performed for purposes of sterilization or family planning is not compensable.
				  The 30 day waiting period which applies to elective sterilizations does not
				  apply to therapeutic hysterectomies. Payment is made for therapeutic
				  hysterectomies only when one of the following circumstances is met:
(1) A properly completed hysterectomy
				  acknowledgement is attached to the claim form. The acknowledgement must clearly
				  state that the patient or her representative was informed, orally and in
				  writing, prior to the surgery that she would be rendered permanently incapable
				  of reproduction.
(2) The surgeon
				  must certify in writing that the patient was sterile prior to the surgery. The
				  reason for the sterility, i.e., post-menopausal, previous tubal ligation, etc.
				  must be given.
(3) The surgeon must
				  certify that the surgery was performed in an emergency, life endangering
				  situation. The life endangering circumstances must be given.
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 317:30-5-20 - Laboratory services

Current through Vol. 41, No. 20, July 1, 2024
For laboratory policies please refer to Part 7,
					 Laboratories (Independent, Physician, And Hospital), of this
					 Chapter.
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 757, eff 1-24-97 (emergency); Amended at 14 Ok
					 Reg 1792, eff 5-27-97; Amended at 14 Ok Reg 2394, eff 5-28-97 (emergency);
					 Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 3413, eff 7-1-99
					 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 19 Ok Reg 2134,
					 eff 6-27-02; Amended at 25 Ok Reg 121, eff 8-1-07 (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 704, eff 2-4-10 (emergency); Amended at 27 Ok Reg 1450,
					 eff 6-11-10
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 317:30-5-20.1 - Drug screening and testing

Current through Vol. 41, No. 20, July 1, 2024
For policy regarding drug screening and testing, please
					 refer to Oklahoma Administrative Code (OAC)
					 317:30-5-101.
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 317:30-5-20.2 - Molecular diagnostic testing utilizing polymerase chain reaction for infectious diseases

Current through Vol. 41, No. 20, July 1, 2024
For policy regarding molecular diagnostic testing utilizing
					 polymerase chain reaction for infectious diseases, please refer to Oklahoma
					 Administrative Code (OAC)
					 317:30-5-102.
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 317:30-5-21 - Unusual procedures

Current through Vol. 41, No. 20, July 1, 2024
A service that is rarely provided, unusual, variable, new
					 or unlisted requires a special report to determine the medical appropriateness
					 or reimbursement rate. Pertinent information should include an adequate
					 definition or description of the nature, extent, and need for the procedure,
					 i.e., operative report. This information should be submitted to OHCA Provider
					 Relations.
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 5 - Individual Providers and Specialties › Part 1 - PHYSICIANS › Section 317:30-5-22.1 - Enhanced services for medically high risk pregnancies

Current through Vol. 41, No. 20, July 1, 2024
(a)
Enhanced services.
Enhanced
				  services are available for pregnant women eligible for SoonerCare and are in
				  addition to services for uncomplicated maternity cases. Women deemed high risk
				  based on criteria established by the Oklahoma Health Care Authority (OHCA) must
				  receive prior authorization for medically necessary enhanced benefits which
				  include:
(1) Prenatal at risk antepartum
				  management;
(2) A combined maximum
				  of five (5) fetal non stress test(s) and biophysical profiles (additional units
				  can be prior authorized for multiple fetuses) with one (1) test per week
				  beginning at thirty-two (32) weeks gestation and continuing to thirty-eight
				  (38) weeks; and
(3) A maximum of
				  three (3) follow-up ultrasounds not covered under Oklahoma Adminisrative Code
				  (OAC)
				  317:30-5-22(b)(2).
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 317:30-5-23 - Newborn care

Current through Vol. 41, No. 20, July 1, 2024
Claims for newborn care and circumcision are filed under
					 the newborn's SoonerCare member ID number.
(1) When there is a newborn child and the
				  mother is receiving SoonerCare benefits, an OKDHS form 08MA015E (FSS-NB-1) or
				  other notification must be submitted to the county OKDHS office. If the mother
				  is not already receiving SoonerCare benefits, an application will need to be
				  completed. Services are billed using the appropriate codes contained in the
				  Physician's Current Procedural Terminology (CPT).
(2) Neonatal intensive care codes (contained
				  in the CPT) are used to report neonatal intensive care services. Certain
				  procedures are bundled into the relevant inpatient neonatal critical care
				  evaluation and management codes and are not reimbursed separately. All other
				  medically-necessary procedures provided are considered for reimbursement using
				  recognized coding and/or editing logic. Additional payment is allowed for
				  standby at Cesarean Section, attendance at delivery or newborn
				  resuscitation.
(3) Payment may be
				  made for an evaluation and management service and newborn circumcision provided
				  by the same provider on the same date of service.
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 2397, eff 2-5-97 (emergency); Amended at 14 Ok
					 Reg 2928, eff 7-11-97; Amended at 16 Ok Reg 151, eff 10-14-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 17 Ok Reg 3199, eff 1-23-01
					 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 24 Ok Reg 2069,
					 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 1 - PHYSICIANS › Section 317:30-5-24 - Radiology

Current through Vol. 41, No. 20, July 1, 2024
(a)
Outpatient and emergency department.
(1) The technical component of outpatient
				  radiological services performed during an emergency department visit is
				  covered.
(2) The professional
				  component of x-rays performed during an emergency department visit is
				  covered.
(3) Ultrasounds for
				  obstetrical care are paid in accordance with provisions found at OAC
				  317:30-5-22(b)(2)(A-C).
(4) Payment is made for charges incurred for
				  the administration of chemotherapy for the treatment of medically necessary and
				  medically approved procedures. Payment for radiation therapy is limited to the
				  treatment of proven malignancies and benign conditions appropriate for
				  stereotactic radiosurgery (e.g.,gamma knife).
(5) Medically necessary screening mammography
				  is a covered benefit. Additional follow-up mammograms are covered when
				  medically necessary.
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 317:30-5-25 - Oklahoma Health Care Authority's Quality Improvement Organization (QIO)

Current through Vol. 41, No. 20, July 1, 2024
All inpatient stays and outpatient observation services are
					 subject to post-payment utilization review by the OHCA's designated Quality
					 Improvement Organization (QIO). These reviews are based on severity of illness
					 and intensity of treatment.
(1) It is
				  the policy and intent of OHCA to allow hospitals and physicians the opportunity
				  to present any and all documentation available to support the medical necessity
				  of an admission and/or extended stay or outpatient observation of a SoonerCare
				  member. If the QIO, upon their initial review determines the admission or
				  outpatient observation services should be denied, a notice is issued to the
				  facility and the attending physician advising them of the decision. This notice
				  also advises that a reconsideration request may be submitted within the
				  specified timeframe on the notice and consistent with the Medicare guidelines.
				  Additional information submitted with the reconsideration request is reviewed
				  by the QIO that utilizes an independent physician advisor. If the denial
				  decision is upheld through this review of additional information, the QIO sends
				  written notification of the denial decision to the hospital, attending
				  physician and the OHCA. Once the OHCA has been notified, the overpayment is
				  processed as per the final denial determination.
(2) If the hospital or attending physician
				  did not request reconsideration from the QIO, the QIO informs OHCA there has
				  been no request for reconsideration and as a result their initial denial
				  decision is final. OHCA, in turn, processes the overpayment as per the denial
				  notice sent to the OHCA by the QIO.
(3) If the QIO's review results in denial and
				  the denial is upheld throughout the review process and refund from the hospital
				  and physician is required, the SoonerCare member cannot be billed for the
				  denied services.
(4) If a hospital
				  or physician believes a hospital admission, continued stay, or outpatient
				  observation service is not medically necessary and thus not SoonerCare
				  compensable but the member insists on treatment, the member is informed that
				  he/she will be personally responsible for all charges.
(A) If a SoonerCare claim is filed and paid
				  and the service is later denied after medical necessity review, the member is
				  not responsible.
(B) If a
				  SoonerCare claim is not filed, the member can be billed.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 2 - PHYSICIAN ASSISTANTS › Section 317:30-5-30 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Eligible providers shall:
(1) Have and maintain current license by the
				  Oklahoma State Board of Medical Licensure and Supervision as specified in
				  Section 519.6 of Title 59 of the Oklahoma
				  Statutes;
(2) Have a current
				  contract with the Oklahoma Health Care Authority (OHCA); and
(3) Have a practice agreement with a
				  SoonerCare contracted delegating physician(s) (who is licensed and in good
				  standing with the State Board of Medical Licensure and Supervision or the State
				  Board of Osteopathic Examiners) concerning the scope of practice of the
				  physician assistant (PA). If at any time the delegating physician(s) change, an
				  updated copy of the practice agreement must be submitted within ten (10)
				  business days to OHCA, Provider Enrollment.
Added at 14 Ok Reg
					 760, eff 1-24-97 (emergency); Added at 14 Ok Reg 1792, eff 5-27-97; Amended at
					 22 Ok Reg 103, eff 7-1-04 (emergency); Amended at 21 Ok Reg 2470, eff
					 7-11-05
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 2 - PHYSICIAN ASSISTANTS › Section 317:30-5-31 - Coverage

Current through Vol. 41, No. 20, July 1, 2024
The OHCA covers medical services (as described in OAC
					 317:30-5, Part 1, Physicians) by a physician assistant (PA) when rendered
					 within the licensure and scope of practice of the PA. Services must be in
					 compliance with the state-specific statutes including Title 59 O.S. §
										519.2, rules and regulations of
					 the applicable practice act.
Added at 14 Ok Reg
					 760, eff 1-24-97 (emergency); Added at 14 Ok Reg 1792, eff 5-27-97; Amended at
					 22 Ok Reg 103, eff 7-1-04 (emergency); Amended at 21 Ok Reg 2470, eff
					 7-11-05
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 2 - PHYSICIAN ASSISTANTS › Section 317:30-5-32 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) Payment for
				  services within the physician assistant's scope of practice shall be made when
				  ordered or performed by the eligible physician assistant if the same service
				  would have been covered if ordered or performed by a physician.
(b) Payment is not made to physician
				  assistant when a service(s) is (are) performed simultaneously with the
				  delegating physician and billed by the physician on the same day.
(c) Payment is made per the methodology
				  established in the Oklahoma Medicaid State Plan.
Added at 14 Ok Reg
					 760, eff 1-24-97 (emergency); Added at 14 Ok Reg 1792, eff
					 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 2 - PHYSICIAN ASSISTANTS › Section 317:30-5-33

Current through Vol. 41, No. 20, July 1, 2024
Added at 14 Ok Reg
					 760, eff 1-24-97 (emergency); Added at 14 Ok Reg 1792, eff
					 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 2 - PHYSICIAN ASSISTANTS › Section 317:30-5-34 - Payment rates [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 14 Ok Reg
					 760, eff 1-24-97 (emergency); Added at 14 Ok Reg 1792, eff 5-27-97; Amended at
					 19 Ok Reg 2134, eff 6-27-02; Revoked at 22 Ok Reg 103, eff 7-1-04 (emergency);
					 Revoked at 21 Ok Reg 2470, eff 7-11-05
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-40 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
(a) All general
				  medical/surgical hospitals and critical access hospitals eligible for
				  reimbursement under this Part must be licensed by the appropriate state survey
				  agency, meet Medicare conditions of participation, and have a current contract
				  on file with the Oklahoma Health Care Authority (OHCA).
(b) Children specialty hospitals must be
				  appropriately licensed and certified and have a current contract with the OHCA.
(c) Eligibility requirements for
				  specialized rehabilitation hospitals are covered in OAC
				  317:30-5-110;
				  inpatient psychiatric hospitals are covered in OAC
				  317:30-5-95;
				  and long term care hospitals are covered in OAC
				  317:30-5-60.
(d) Certain providers who provide
				  professional and other services within an inpatient or outpatient hospital
				  require separate contracts with the OHCA.
(e) Reimbursement for laboratory services is
				  made in accordance with the Clinical Laboratory Improvement Amendment of 1988
				  (CLIA). These regulations provide that payment may be made only for services
				  furnished by a laboratory that meets CLIA conditions. Eligible providers must
				  be certified under the CLIA program and have obtained a CLIA ID number from the
				  Center for Medicare and Medicaid Services (CMS) and have a current contract on
				  file with this Authority.
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 3469, eff 8-1-00 (emergency); Amended at 18 Ok
					 Reg 1130, eff 5-11-01; Amended at 24 Ok Reg 317, eff 12-1-06 (emergency);
					 Amended at 24 Ok Reg 905, eff 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-40.1 - General information

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  This Chapter applies to coverage in an inpatient and/or outpatient setting.
				  Coverage is the same for adults and children unless otherwise
				  indicated.
(b)
Professional
				  Services.
Payment is made to a participating hospital group or
				  corporation for hospital based physician's services. The hospital must have a
				  Hospital Group Physician's Contract with OHCA for this method of
				  billing.
(c)
Prior
				  Authorization.
OHCA requires prior authorization for certain procedures
				  to validate the medical need for the service.
(d)
Medical necessity.
Medical
				  necessity requirements are listed at OAC
				  317:30-3-1(f)
				  and 317:30-5-20.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-40.2 - Definitions [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-41 - Inpatient hospital coverage/limitations

Current through Vol. 41, No. 20, July 1, 2024
(a) Covered hospital inpatient services are
				  those medically necessary services which require an inpatient stay ordinarily
				  furnished by a hospital for the care and treatment of inpatients and which are
				  provided under the direction of a physician or dentist in an institution
				  approved under OAC:317:30:5-40.1(a) or (b). Claims for inpatient admissions in
				  acute care or critical access hospitals are reimbursed the lesser of the billed
				  charges or the Diagnosis Related Groups (DRG) amount.
(b)
Inpatient status.
OHCA
				  considers a member an inpatient when the member is admitted to the hospital and
				  is counted in the midnight census. In situations when a member inpatient
				  admission occurs and the member dies, is discharged following an obstetrical
				  stay, or is transferred to another facility on the day of admission, the member
				  is also considered an inpatient of the hospital.
(1)
Same day admission.
If a
				  member is admitted and dies before the midnight census on the same day of
				  admission, the member is considered an inpatient.
(2)
Same day admission/discharge
				  obstetrical and newborn stays.
A hospital stay is considered inpatient
				  stay when a member is admitted and delivers a baby, even when the mother and
				  baby are discharged on the date of admission (i.e., they are not included in
				  the midnight census). This rule applies when the mother and/or newborn are
				  transferred to another hospital.
(3)
Same day admission/discharges other
				  than obstetrical and newborn stays.
In the event a member is admitted as
				  an inpatient, but is determined to not qualify for an inpatient payment based
				  on OHCA criteria, the hospital may bill on an outpatient claim for the
				  ancillary services provided during that time.
(4)
Discharges and Transfers.
A
				  hospital inpatient is considered discharged from a hospital paid under the
				  DRG-based payment system when:
(A) The
				  patient is formally released from the hospital; or
(B) The patient dies in the hospital; or
(C) The patient is transferred to
				  a hospital that is excluded from the DRG-based payment system, or transferred
				  to a distinct part psychiatric or rehabilitation unit of the same hospital.
				  Such instances will result in two or more claims. Effective January 1, 2007,
				  distinct part psychiatric and rehabilitation units excluded from the Medicare
				  Prospective Payment System (PPS) of general medical surgical hospitals will
				  require a separate provider identification number.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-41.1 - Acute inpatient psychiatric services

Current through Vol. 41, No. 20, July 1, 2024
(a) Inpatient stays in a psychiatric unit of
				  a general medical/ surgical hospital are covered for members of any age. See
				  OAC
				  317:30-5-95
				  for coverage in a freestanding psychiatric hospital or psychiatric residential
				  treatment facility.
(b)
Utilization Control.
All psychiatric admissions must be prior
				  authorized. SoonerCare utilization control requirements applicable to inpatient
				  psychiatric services in freestanding psychiatric hospitals apply to acute care
				  hospitals. Acute care hospitals are required to maintain the same level of
				  documentation on individuals receiving psychiatric services as the freestanding
				  psychiatric facilities (refer to OAC
				  317:30-5-95.12
				  ).
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07