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 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.46 - Residential substance use disorder (SUD) - Covered services and medical necessity criteria

Current through Vol. 41, No. 20, July 1, 2024
(a) In order for the
				  services described in this Section to be covered, individuals shall:
(1) Be diagnosed with an SUD as described in
				  the most recent edition of the DSM; and
(2) Meet residential level of care as
				  determined through completion of the designated ASAM placement tool as required
				  by the Oklahoma Department of Mental Health and Substance Abuse Services
				  (ODMHSAS).
(3) For additional
				  medical necessity criteria, refer to the ODMHSAS Prior Authorization Manual
				  available at
www.odmhsas.org/arc.htm
.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.48 - Staff training

Current through Vol. 41, No. 20, July 1, 2024
(a) All clinical and
				  direct care staff shall have non-physical intervention training in techniques
				  and philosophies addressing appropriate non-violent interventions for
				  potentially physical interpersonal conflicts, staff attitudes which promote
				  dignity and enhanced self-esteem, keys to effective communication skills,
				  verbal and non-verbal interaction and non-violent intervention within thirty
				  (30) days of being hired with updates each calendar year thereafter.
(b) All staff shall receive training in
				  accordance with OAC
				  450:18-9-3(f).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.49 - Medication policies and records

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The facility shall have policies in place addressing the safe storage,
				  handling, and administration of medications.
(b) Medication records shall be maintained in
				  accordance with OAC
				  450:18-7-144.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.50 - Residential substance use disorder (SUD) - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) In order to be
				  eligible for payment, residential treatment providers of SUD treatment services
				  must have an approved provider agreement on file with the OHCA. Through this
				  agreement, the residential provider assures that they are in compliance with
				  all applicable federal and State Medicaid law and regulations, including, but
				  not limited to, OHCA administrative rules, ODMHSAS administrative rules, and
				  the Oklahoma Medicaid State Plan.
(b) Covered SUD treatment services for
				  adolescents and adults in SUD residential treatment shall be reimbursed
				  utilizing the per diem rates for each level of care. All SUD residential
				  treatment services must be prior authorized by the OHCA or its designated agent
				  before the service is rendered by an eligible provider. Without prior
				  authorization, payment is not authorized.
(c) Separate payment may be made for
				  medications, physician services, and treatment services provided to dependent
				  children in accordance with the Oklahoma Medicaid State Plan. Separate payment
				  for such services will follow existing prior authorization requirements, if
				  applicable.
(d) Treatment services
				  for dependent children accompanying a parent to treatment shall be reimbursed
				  on a fee-for-service basis in accordance with the Oklahoma Medicaid State Plan.
				  Outpatient services rendered to dependent children may be provided by the
				  residential facility if appropriately certified or a separate outpatient
				  provider. Such services shall not duplicate any services provided by the
				  residential provider that are reimbursed through the residential per dime
				  rate.
(e) The following services
				  are excluded from coverage/reimbursement:
(1)
				  Room and board;
(2) Services or
				  components that are not provided to or exclusively for the treatment of the
				  member;
(3) Services or components
				  of services of which the basic nature is to supplant housekeeping or basic
				  services for the convenience of a member receiving covered services;
(4) Physician directed services and
				  medications (these services are reimbursed outside of the residential SUD per
				  diem);
(5) Telephone calls or other
				  electronic contacts (not inclusive of telehealth); and
(6) Field trips, social, or physical exercise
				  activity groups.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.51 - Residential substance use disorder (SUD) - reporting of suspected child abuse/neglect

Current through Vol. 41, No. 20, July 1, 2024
Instances of child abuse and/or neglect are to be reported
					 in accordance with state law, including, but not limited to, Section (§)
					 1-2-101 of Title 10A of the Oklahoma Statutes and 43A O.S. §
										10-104. Any person suspecting
					 child abuse or neglect shall immediately report it to the Oklahoma Department
					 of Human Services (OKDHS) hotline, at 1-800-522-3511; any person suspecting
					 abuse, neglect, or exploitation of a vulnerable adult shall immediately report
					 it to the local DHS County Office, municipal or county law enforcement
					 authorities, or, if the report occurs after normal business hours, the OKDHS
					 hotline. Health care professionals who are requested to report incidents of
					 domestic abuse by adult victims with legal capacity shall promptly make a
					 report to the nearest law enforcement agency, per 22 O.S. §
					 58.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.52 - Documentation of records for adults receiving inpatient services

Current through Vol. 41, No. 20, July 1, 2024
(a) All
				  documentation for services provided under active treatment must be documented
				  in an individual note and reflect the content of each session provided.
				  Services documentation must include, at a minimum, the following:
(1) Date;
(2) Start and stop time for each
				  session;
(3) Dated signature of the
				  therapist and/or staff that provided the service;
(4) Credentials of the therapist;
(5) Specific problem(s) addressed (problems
				  must be identified on the plan of care);
(6) Method(s) used to address
				  problems;
(7) Progress made towards
				  goals;
(8) Member's response to the
				  session or intervention; and
(9)
				  Any new problem(s) identified during the session.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96 - Reimbursement for inpatient services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
					 19 Ok Reg 2762, eff 4-30-02 (emergency); Amended at 20 Ok Reg 1193, eff
					 5-27-03; Amended at 22 Ok Reg 404, eff 12-1-04 (emergency); Amended at 21 Ok
					 Reg 2486, eff 7-11-05; Revoked at 23 Ok Reg 2508, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.1 - Cost reports [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Revoked at
					 23 Ok Reg 2508, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.3 - Methods of payment

Current through Vol. 41, No. 20, July 1, 2024
(a)
Reimbursement.
(1) Covered
				  inpatient psychiatric chemical dependency detoxification/withdrawal management
				  services will be reimbursed using one (1) of the following methodologies:
(A) Diagnosis related group (DRG);
(B) Cost-based; or
(C) A predetermined per diem payment.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.4 - Outlier intensity adjustment

Current through Vol. 41, No. 20, July 1, 2024
Subject to approval by the Centers for Medicare and
					 Medicaid Services (CMS), an outlier payment may be made to instate hospitals
					 and PRTFs on a case by case basis, to promote access for those members who
					 require expensive care. The intent of the outlier adjustment is to reflect the
					 increased staffing requirements, co-morbidities and longer lengths of stay, for
					 children with developmental disabilities or eating disorders. This adjustment
					 is limited to 60 days annually.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended
					 at 28 Ok Reg 1452, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.5 - Disproportionate share hospitals (DSH)

Current through Vol. 41, No. 20, July 1, 2024
Reimbursement for DSH is determined in accordance with the
					 methodology for inpatient hospital services as described in Attachment 4.19 A
					 of the Medicaid State Plan. Copies of the plan may be obtained by writing the
					 Oklahoma Health Care Authority, 4345 North Lincoln Boulevard, Oklahoma City, OK
					 73105 or may be downloaded from the OHCA website.
Added at 23 Ok Reg
					 2508, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.6 - Payment for Medicare/Medicaid dual eligible individuals

Current through Vol. 41, No. 20, July 1, 2024
(a)
For dual
				  eligible members.
Payment is made for Medicare-related deductibles
				  and/or coinsurance.
(b)
For
				  individuals who are not eligible for Part A services.
For individuals
				  who have exhausted Medicare Part A benefits, claims must be accompanied by a
				  statement from the Medicare Part A Regional Administrative Contractor showing
				  the date benefits were exhausted.
Added at 23 Ok Reg
					 2508, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.7 - Cost reports

Current through Vol. 41, No. 20, July 1, 2024
Each hospital or PRTF submits to the OHCA its Medicare Cost
					 Report (HCFA 2552), including Medicaid-specific information (as appropriate),
					 for the annual cost reporting period. PRTFs who do not file a Medicare Cost
					 Report must submit a cost report in a format designated by the OHCA. Failure to
					 submit the required completed cost report is grounds for the OHCA to determine
					 that a provider is not in compliance with its contractual requirements. The
					 OHCA enters into a Common Audit Agreement with a designated fiscal intermediary
					 to audit Medicaid cost reports. Hospitals submit a copy of their cost reports
					 to this designated fiscal intermediary. All payments made to providers are
					 subject to adjustment based upon final (audited) cost report
					 information.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended
					 at 28 Ok Reg 1452, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-96.8 - Psychiatric Residential Treatment Facility payments to subcontractors

Current through Vol. 41, No. 20, July 1, 2024
(a) Psychiatric
				  Residential Treatment Facilities (PRTFs) that receive a pre-determined
				  all-inclusive per diem payment must provide routine, ancillary and professional
				  services. In the event the member receives an ancillary service, the PRTF is
				  responsible for making timely payment to the subcontractor or other
				  provider.
(b) For purposes of
				  subsection (a) of this Section, timely payment or adjudication means payment or
				  denial of a clean claim within 45 days of presentation to the PRTF.
(c) No subcontractor of the PRTF may charge
				  more than the OHCA fee schedule for SoonerCare compensable services.
(d) The subcontractor may not bill the
				  SoonerCare member until the PRTF has refused payment.
Added at 25 Ok Reg
					 673, eff 2-1-08 through 7-14-08 (emergency)1; Added
					 at 25 Ok Reg 2703, eff 7-25-08
1This emergency action expired
					 before being superseded by a permanent action. Upon expiration of an emergency
					 action enacting a new Section, the Section is no longer effective. Therefore,
					 on 7-15-08 (after the 7-14-08 expiration of this emergency action), Section
					 317:30-5-96.8 was no longer effective, and remained as such until added again
					 by permanent action on 7-25-08.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-97 - Reporting abuse and/or neglect

Current through Vol. 41, No. 20, July 1, 2024
Instances of abuse and/or neglect are to be reported in
					 accordance with state law, including, but not limited to, 10A O.S. §
					 1-2-101 and 43A O.S. § 10-104. Any person suspecting child abuse or
					 neglect shall immediately report it to the Oklahoma Department of Human
					 Services (DHS) hotline, at 1-800-522-3511; any person suspecting abuse,
					 neglect, or exploitation of a vulnerable adult shall immediately report it to
					 the local DHS County Office, municipal or county law enforcement authorities,
					 or, if the report occurs after normal business hours, the DHS hotline. Health
					 care professionals who are requested to report incidents of domestic abuse by
					 adult victims with legal capacity shall promptly make a report to the nearest
					 law enforcement agency, per 22 O.S. §
										58.
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
					 26 Ok Reg 2081, eff 6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-98 - Claim Form [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; 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 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-100 - Laboratory services

Current through Vol. 41, No. 20, July 1, 2024
This Part covers the guidelines for payment of laboratory
					 services by a provider in his/her office, a certified hospital or independent
					 laboratory, and for a pathologist's interpretation of laboratory
					 procedures.
(1)
Physician and
				  clinic provider laboratories.
Physician and clinic providers may be
				  reimbursed for compensable clinical diagnostic laboratory services only when
				  they personally perform or supervise the performance of the test. If a
				  physician or clinic provider refers specimen to a certified laboratory or a
				  hospital laboratory serving outpatients, the certified laboratory or the
				  hospital must bill for performing the test.
(2)
Independent and hospital
				  laboratories.
Independent and hospital laboratories will be required to
				  submit a letter to OHCA Provider Enrollment along with their other required
				  contracting documents. The reference laboratory must be identified on the claim
				  as well as the following information for any and all reference laboratories:
(A) Name;
(B) Address; and
(C) Clinical Laboratory Improvement Amendment
				  of 1988 (CLIA) ID.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-101 - Drug screening and testing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Purpose.
Drug testing is performed for undisclosed drug use and/or
				  abuse, and to verify compliance with treatment. Testing for drugs of abuse to
				  monitor treatment compliance should be included in the treatment plan for pain
				  management when chronic opioid therapy is involved.
(1) Qualitative (presumptive) drug testing
				  may be used to determine the presence or absence of a drug or drug metabolite
				  in the sample and is expressed as a positive or negative result. Qualitative
				  testing can be performed by a Clinical Laboratory Improvement Amendment of 1988
				  (CLIA) waived or moderate complexity test, or by a high complexity testing
				  method.
(2) Quantitative
				  (definitive) drug testing is specific to the drug or metabolite being tested
				  and is expressed as a numeric result or numeric level which verifies
				  concentration.
(3) Specimen
				  validity testing is used to determine if a specimen has been diluted,
				  adulterated, or substituted. Specimen validity tests include, but are not
				  limited to, creatinine, oxidants, specific gravity, urine pH, nitrates, and
				  alkaloids.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-102 - Molecular diagnostic testing utilizing polymerase chain reaction for infectious diseases

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following words and terms, when used in this
				  Section, shall have the following meaning, unless the context clearly indicates
				  otherwise.
(1)
"Amplified probe
				  technique"
means technique without quantification, a detection method in
				  which the sensitivity of the assay is improved over direct probe
				  techniques.
(2)
"Direct probe
				  technique"
means detection methods where nucleic acids are detected
				  without initial amplification processing.
(3)
"Polymerase chain reaction
				  (PCR)"
means a biochemical laboratory technique used to make thousands
				  or even millions of copies of a segment of DNA. It is commonly used to amplify
				  a small amount of specifically targeted DNA from among a mixture of DNA
				  samples. It is also known as Nucleic Acid Amplification Test (NAAT).
(4)
"Probe with quantification
				  technique"
means methods used to report absolute or relative amounts of
				  nucleic acid sequences in the original sample.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-103 - Coverage and payment

Current through Vol. 41, No. 20, July 1, 2024
(a)
Payment
				  eligibility.
To be eligible for payment as a laboratory/pathology
				  service, the service must be:
(1) Ordered and
				  provided by or under the direction of a physician or other licensed
				  practitioner within the scope of practice as defined by state law;
(2) Provided in a hospital, physician, or
				  independent laboratory;
(3)
				  Directly related to the diagnosis and treatment of a medical
				  condition;
(4) Authorized under the
				  laboratory's Clinical Laboratory Improvement Amendment of 1988 (CLIA)
				  certification; and
(5) Considered
				  medically necessary as defined in Oklahoma Administrative Code
				  317:30-3-1(f)
				  and 317:30-5-100.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-104 - Non-covered procedures

Current through Vol. 41, No. 20, July 1, 2024
The following procedures by laboratories are not
					 covered:
(1) Tissue examinations of
				  teeth and foreign objects.
(2)
				  Tissue examination of lens after cataract surgery except when the member is
				  under twenty-one (21) years of age.
(3) Charges for autopsy.
(4) Hair analysis for trace metal
				  analysis.
(5) Procedures deemed
				  experimental or investigational. For more information regarding experimental or
				  investigational including clinical trials, see Oklahoma Administrative Code
				  317:30-3-57.1.
(6) Professional component charges for
				  inpatient clinical laboratory services.
(7) Inpatient clinical laboratory
				  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 2922, eff 7-1-02 (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 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-105

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 5 - Individual Providers and Specialties › Part 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-106

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 17 Ok Reg 3358, eff 8-1-01 (emergency); Amended 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 7 - LABORATORIES (INDEPENDENT, PHYSICIAN, AND HOSPITAL) › Section 317:30-5-107 - Claim form [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 8 - REHABILITATION HOSPITALS › Section 317:30-5-110 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
To be eligible for reimbursement, all licensed
					 rehabilitation hospitals must be Medicare certified and have a current contract
					 on file with the Oklahoma Health Care Authority (OHCA).
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff
					 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 8 - REHABILITATION HOSPITALS › Section 317:30-5-111 - Coverage for adults

Current through Vol. 41, No. 20, July 1, 2024
For persons twenty-one (21) years of age or older, payment
					 is made to hospitals for inpatient services as described in this section.
(1) All general inpatient hospital
				  services which are not provided under the Diagnosis Related Group (DRG) payment
				  methodology for all persons twenty-one (21) years of age or older is limited to
				  ninety (90) days per person per state fiscal year (July 1 through June 30). The
				  ninety (90) day limitation applies to both hospital and physician services. No
				  exceptions or extensions will be made to the ninety (90) day inpatient services
				  limitation.
(2) All inpatient
				  stays are subject to post-payment utilization review by the Oklahoma Health
				  Care Authority's (OHCA) designated Quality Improvement Organization (QIO).
				  These reviews are based on severity of illness and intensity of treatment.
(A) 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 of a SoonerCare member. 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. This notice also
				  advises that a reconsideration request may be submitted within the specified
				  time frame 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.
(B) 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.
(C) If an OHCA, or its designated agent,
				  review results in denial and the denial is upheld throughout the appeal process
				  and refund from the hospital and physician is required, the member cannot be
				  billed for the denied services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 8 - REHABILITATION HOSPITALS › Section 317:30-5-112 - Coverage for children

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to rehabilitation hospitals for medical
					 services for persons under the age of 21 within the scope of the Authority's
					 Medical Programs, provided the services are reasonable for the diagnosis and
					 treatment of illness or injury, or to improve the functioning of a malformed
					 body member. Medical and surgical services are comparable to those listed for
					 adults except all medically necessary inpatient hospital services, other than
					 psychiatric services, for all persons under the age of 21 will not be
					 limited.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff
					 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 8 - REHABILITATION HOSPITALS › Section 317:30-5-113 - Medicare eligible individuals

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to hospitals for services to Medicare
					 eligible individuals as set forth in this section.
(1)
Individuals eligible for Part A and
				  Part B.
(A) Payment is made utilizing
				  the Medicaid allowable for comparable Part B services.
(B) Payment is made for the coinsurance
				  and/or deductible for Part A services for categorically needy
				  individuals.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 8 - REHABILITATION HOSPITALS › Section 317:30-5-114 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
Payment is made at the lesser of the facilities usual and
					 customary fee or the OHCA fixed per diem rate.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff
					 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-120 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Long term care facilities may receive payment for the
					 provision of nursing care under the Title XIX Medicaid Program only when they
					 are properly licensed and certified by the Oklahoma Department of Health, meet
					 Federal and State requirements and hold a valid contract with the Oklahoma
					 Health Care Authority (OHCA) to provide long term care services . All long term
					 care facility contracts are time limited with specific effective and expiration
					 dates.
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 1203, eff 1-9-96 (emergency); Amended at 13 Ok
					 Reg 2523, eff 6-27-96; Amended at 14 Ok Reg 265, eff 9-17-96 (emergency);
					 Amended at 14 Ok Reg 1780, 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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-121 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Payment is made for compensable long term care for adults
				  after the member has been determined medically eligible to receive such care.
(b)
Children.
Coverage for children is the same as adults.
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 1203, eff 1-9-95 (emergency); Amended at 13 Ok
					 Reg 2523, eff 6-27-96; Amended 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 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-124 - Facility licensure

Current through Vol. 41, No. 20, July 1, 2024
(a)
Nursing home license required.
A NF must meet state nursing home
				  licensing standards to provide, on a regular basis, health related care and
				  services to individuals who do not require hospital care.
(1) In order for long term care facilities to
				  receive payment from the OHCA for the provision of nursing care, they must be
				  currently licensed under provisions of Title 63 O.S., Nursing Home Care Act,
				  Section
				  1-1900.1,
				  et seq.
(2) The State Department
				  of Health is responsible for the issuance, renewal, suspension , and revocation
				  of a facility's license in addition to the enforcement of the standards. The
				  denial, suspension , or revocation of a facility's license is subject to appeal
				  to the State Department of Health. All questions regarding a facility's license
				  should be directed to the State Department of Health.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-126 - Therapeutic leave and Hospital leave

Current through Vol. 41, No. 20, July 1, 2024
Therapeutic leave is any planned leave other than
					 hospitalization that is for the benefit of the patient. Hospital leave is
					 planned or unplanned leave when the patient is admitted to a licensed hospital.
					 Therapeutic leave must be clearly documented in the patient's plan of care
					 before payment for a reserved bed can be made.
(1) Effective July 1, 1994, the nursing
				  facility may receive payment for a maximum of seven (7) days of therapeutic
				  leave per calendar year for each recipient to reserve the bed.
(2) No payment shall be made to a nursing
				  facility for hospital leave.
(3)
				  The Intermediate Care Facility for Individuals with Intellectual Disabilities
				  (ICF/IID) may receive payment for a maximum of 60 days of therapeutic leave per
				  calendar year for each recipient to reserve a bed. No more than 14 consecutive
				  days of therapeutic leave may be claimed per absence. Recipients approved for
				  ICF/IID on or after July 1 of the year will only be eligible for 30 days of
				  therapeutic leave during the remainder of that year. No payment shall be made
				  for hospital leave.
(4) Midnight is
				  the time used to determine whether a patient is present or absent from the
				  facility. The day of discharge for therapeutic leave is counted as the first
				  day of leave, but the day of return from such leave is not counted.
(5) Therapeutic leave balances are recorded
				  on the Medicaid Management Information System (MMIS). When a patient moves to
				  another facility, it is the responsibility of the transferring facility to
				  forward the patient's leave records to the receiving facility.
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 909, eff 8-1-95 (emergency); Amended at 13 Ok Reg
					 395, eff 1-1-96 (emergency); Amended at 13 Ok Reg 1675, eff 5-27-96; Amended at
					 14 Ok Reg 265, eff 9-17-96 (emergency); Amended at 14 Ok Reg 1780, eff 5-27-97;
					 Amended at 25 Ok Reg 2668, eff 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-127 - Notification of nursing facility changes

Current through Vol. 41, No. 20, July 1, 2024
It is important that the nursing facility keep the OHCA
					 Provider Enrollment and Contracts Unit informed of any change in administrator,
					 operator, mailing address, or telephone number of the facility. Inaccurate
					 information can cause a delay in receipt of payments or correspondence. The
					 facility should also report all changes to the State Department of Health and
					 the Oklahoma State Board of Nursing Homes.
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 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 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-128

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 14 Ok Reg 265, eff 9-17-96 (emergency); Amended at 14 Ok
					 Reg 1780, 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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-129 - Required monthly notifications

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The Notification Regarding Patient in a Nursing Facility or ICF/IID form is
				  completed and forwarded to the local DHS office by the facility each time a
				  member is admitted to or discharged from the facility.
(b) A Computer Generated Notice or the Notice
				  to Client Regarding Long-Term Medical Care form is used by the county office to
				  notify the member and the facility of the amount of money, if any, the member
				  is responsible for paying to the facility and the action taken with respect to
				  the member's eligibility for nursing facility care. This form reflects dates of
				  transfer between facilities and termination of eligibility for any reason.
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 1675, eff 5-27-96; Amended at 13 Ok Reg 909, eff
					 8-1-96 (emergency); Amended at 14 Ok Reg 265, eff 9-17-96 (emergency); Amended
					 at 14 Ok Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 706, eff 12-15-97
					 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 17 Ok Reg 3509,
					 eff 9-1-00 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 21
					 Ok Reg 2466, 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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-130 - Inspections of care in Intermediate Care Facilities for the Mentally Retarded (ICF/MR)

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) is responsible
					 for periodic inspections of care and services in each ICF/MR providing services
					 for Title XIX applicants and recipients. The inspection of care reviews are
					 made by the OHCA or its designated agent. The frequency of inspections is based
					 on the quality of care and service being provided in a facility and the
					 condition of recipients in the facility. However, the care and services
					 provided to each recipient in the facility must be inspected at least annually.
					 No notification of the time of the inspection will be given to the facility
					 prior to the inspections.
(1) The
				  purpose of periodic inspections is to determine:
(A) The level of care required by each
				  patient for whom Title XIX benefits have been requested or approved.
(B) The adequacy of the services available in
				  the particular facility to meet the current health, rehabilitative and social
				  needs of each recipient in an ICF/MR and promote the maximum physical, mental,
				  and psychosocial functioning of the recipient receiving care in such
				  facility.
(C) The necessity and
				  desirability of the continued placement of each patient in such
				  facility.
(D) The feasibility of
				  meeting the health care needs and the recipient's rehabilitative needs through
				  alternative institutional or noninstitutional services.
(E) If each recipient in an institution for
				  the mentally retarded or persons with related conditions is receiving active
				  treatment.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-131 - Rates of payments

Current through Vol. 41, No. 20, July 1, 2024
(a) Rates of
				  payments shown on the Fee Schedule for Nursing Facilities and ICF/MR's are
				  based on the cost of the nursing facility level of care provided and the
				  nursing care staffing pattern. The rate of payment to a nursing facility is
				  also determined by the type of facility and quality of care rating.
(b) A rate of payment established by the
				  facility for private patients is not under the jurisdiction of OHCA. A facility
				  must establish and maintain identical policies and practices regarding
				  transfer, discharge, and the provision of services under the State Plan for all
				  individuals regardless of source of payment. The facility may charge any amount
				  for services furnished to non-Medicaid residents consistent with the written
				  notice requirements describing the charges found at
				  42 CFR
				  483.10.
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 265, eff 9-17-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 706, eff 12-15-97 (emergency);
					 Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 24 Ok Reg 2819, eff 7-1-07
					 (emergency); Amended at 25 Ok Reg 1200, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-131.1 - Wage enhancement [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 1887, eff 3-17-98 (emergency) ; Added
						at 16 Ok Reg 1429, eff 5-27-99 ; Amended at 16 Ok Reg 3613, eff 8-3-99
						(emergency) ; Amended at 17 Ok Reg 1204, eff 5-11-00 ; Amended at 23 Ok Reg
						771, eff 3-9-06 (emergency) ; Amended at 23 Ok Reg 2440, eff 6-25-06 ; Amended
						at 30 Ok Reg 1195, 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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-132.1 - Reconsideration of cost report adjustments

Current through Vol. 41, No. 20, July 1, 2024
(a) A long-term care facility may request
				  reconsideration of cost report adjustment(s)/finding(s) within thirty (30)
				  calendar days of the date of notification of the cost adjustment(s) by
				  submitting a request for reconsideration to the Oklahoma Health Care Authority
				  (OHCA), Chief Financial Officer (CFO), Finance/NF Cost Reporting, 4345 North
				  Lincoln Boulevard, Oklahoma City, Oklahoma 73105.
(b) Simultaneous with the request for
				  reconsideration, the long-term care facility shall submit a statement as to why
				  the request for reconsideration is being made and may submit any new or
				  additional information that he or she wishes the CFO or his/her designee to
				  consider. Any request for an informal meeting according to subsection (c),
				  below, must be made at the same time as the request for reconsideration.
(c) At the request of the
				  long-term care facility, the reconsideration may be conducted by the CFO or
				  his/her designee as:
(1) An informal meeting
				  between the long-term care facility and the CFO or his/her designee; or
(2) A review by the CFO or his/her
				  designee of the information described below:
(A) A review of all information submitted by
				  the long-term care facility; and,
(B) A review of the cost report adjustments
				  made by the OHCA, in order to determine the accuracy of the adjustments.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-132.2 - Allowable costs

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) shall reimburse
					 long-term care facilities in accordance with its federally-approved Oklahoma
					 Medicaid Plan. According to the Oklahoma Medicaid Plan, per-diem rates for
					 long-term care facilities are established on, among other things, analyses of
					 annual uniform cost reports. These reports may only include allowable costs, as
					 follows:
(1) To be allowable, the
				  costs shall be reasonable and necessary for services related to resident care,
				  and pertinent to the operation of the long-term care facility. More
				  specifically:
(A) To be reasonable, costs
				  shall be such as would ordinarily be incurred for comparable services provided
				  by comparable facilities, for example, facilities of similar size and level of
				  care; and
(B) To be necessary,
				  costs related to patient care must be common and accepted occurrences; and,
(C) Allowable costs for services
				  and items directly related to resident care include routine services, as
				  established by Oklahoma Administrative Code (OAC)
				  317:30-5-133.1,
				  and quality of care assessment fees, as established by OAC
				  317:30-5-131.2.
				  Ancillary services, as established by OAC
				  317:30-5-133.2,
				  are not allowable costs, but may be reimbursed outside the long-term care
				  facility rate, unless reimbursement is available from Medicare or other
				  insurance or benefit programs.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-133 - Payment methodologies

Current through Vol. 41, No. 20, July 1, 2024
(a)
Private Nursing Facilities.
(1)
Facilities.
Private Nursing Facilities include:
(A) Nursing Facilities serving adults (NF),
(B) Nursing Facilities serving
				  Aids Patients,
(C) Nursing
				  Facilities serving Ventilator Patients,
(D) Intermediate Care Facilities for
				  Individuals with Intellectual Disabilities (ICF/IID),
(E) Intermediate Care Facilities with 16 beds
				  or less serving severely or profoundly intellectually disabled members ,
				  and
(F) Payment will be made for
				  non-routine nursing facility services identified in an individual treatment
				  plan prepared by the State Intellectual Disabilities (ID) Authority. Services
				  are limited to individuals approved for NF and specialized services as the
				  result of a PASRR/ID Level II screen. The per diem add-on is calculated as the
				  difference in the statewide average standard private ID base rate and the
				  statewide NF base rate. If the standard private ID average base rate falls
				  below the standard NF base rate or equals the standard facility base rate for
				  regular NFs, the payment will not be adjusted for specialized services.