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 317:30-5-95.24 - Prior authorization of inpatient psychiatric services for individuals under twenty-one (21)

Current through Vol. 41, No. 20, July 1, 2024
(a) All inpatient
				  psychiatric services for members under twenty-one (21) years of age must be
				  prior authorized by the OHCA or its designated agent. All inpatient Acute,
				  Acute II, and PRTF services will be prior authorized for an approved length of
				  stay. Admission requirements for services must be provided in accordance with
				  42 C.F.R. Part 441 and 456 . Additional information will be required for
				  SoonerCare-compensable approval on enhanced treatment units or in special
				  population programs.
(b) Unit
				  staffing ratios shall always meet the requirements in OAC
				  317:30-5-95.24(c), (d), (h) and
				  (i). Out-of-state facilities may adhere to
				  the staffing requirements of the state in which the services are provided if
				  the staff ratio is sufficient to ensure patient safety and that patients have
				  reasonable and prompt access to services. The facility cannot use staff that is
				  also on duty in other units of the facility in order to meet the unit staffing
				  ratios. Patients shall be grouped for accommodation by gender, age, and
				  treatment needs. At a minimum, children, adolescent, and adult treatment
				  programs shall be separate with distinct units for each population. A unit is
				  determined by separate and distinct sleeping, living, and treatment areas often
				  separated by walls and/or doors. A unit that does not allow clear line of sight
				  due to the presence of walls or doors is considered a separate unit. Each
				  individual unit shall have assigned staff to allow for appropriate and safe
				  monitoring of patients and to provide active treatment.
(c) In Acute and Acute II settings, at least
				  one (1) registered nurse (RN) must be on duty per unit at all times, with
				  additional RNs to meet program needs. RNs must adhere to Oklahoma State
				  Department of Health (OSDH) policy at OAC
				  310:667-15-3 and
				  310:667-33-2(a)(3).
(d) Acute, non-specialty Acute II, and
				  non-specialty PRTF programs require a staffing ratio of one (1) staff: six (6)
				  patients during routine waking hours and one (1) staff: eight (8) patients
				  during time residents are asleep with twenty-four (24) hour nursing care
				  supervised by an RN for management of behaviors and medical complications. For
				  PRTF programs, at a minimum, a supervising RN must be available by phone and
				  on-site within one (1) hour. If the supervising RN is off-site, then an RN or
				  licensed practical nurse (LPN) must be on-site to adhere to a twenty-four (24)
				  hour nursing care coverage ratio of one (1) staff: thirty (30) patients during
				  routine waking hours and one (1) staff: forty (40) patients during time
				  residents are asleep.
(e) Specialty
				  treatment at Acute II or PRTF is a longer-term treatment that requires a higher
				  staff-to-member ratio because of the need for constant, intense, and immediate
				  reinforcement of new behaviors to develop an understanding of the behaviors.
				  The environment of specialized residential treatment centers requires special
				  structure and configuration (e.g., sensory centers for autistic members) and
				  specialized training for the staff in the area of the identified specialty. The
				  physician, Advanced Practice Registered Nurse (APRN) with psychiatric
				  certification or Physician Assistant (PA) will see the child at least one (1)
				  time a week.
(f) An Acute II or
				  PRTF will not be considered a specialty treatment program for SoonerCare
				  without prior approval of the OHCA behavioral health unit.
(g) A treatment program that has been
				  approved as a specialized treatment program must maintain medical records that
				  document the degree and intensity of the psychiatric care delivered to the
				  members and must meet active treatment requirements found at OAC
				  317:30-5-95.34.
(h) Criteria for classification as a
				  specialty Acute II will require a staffing ratio of one (1) staff: four (4)
				  patients at a minimum during routine waking hours and one (1) staff: six (6)
				  patients during time residents are asleep with twenty-four (24) hour nursing
				  care supervised by a RN for management of behaviors and medical complications.
				  The specialty Acute II will be a secure unit, due to the complexity of needs
				  and safety considerations. Admissions and authorization for continued stay for
				  a specialty Acute II will be restricted to members who meet the medical
				  necessity criteria at OAC
				  317:30-5-95.29 and OAC
				  317:30-5-95.30 for the respective
				  level of care and meet the additional criteria found in the Behavioral Health
				  Services Medical Necessity Criteria Manual, available on OHCA's website,
www.oklahoma.gov/ohca
.
(i) Criteria for classification as a
				  specialty PRTF will require a staffing ratio of one (1) staff: four (4)
				  patients at a minimum during routine waking hours and one (1) staff: six (6)
				  patients during time residents are asleep with twenty-four (24) hour nursing
				  care supervised by a RN for management of behaviors and medical complications.
				  The specialty PRTF will be a secure unit, due to the complexity of needs and
				  safety considerations. Admissions and authorization for continued stay in a
				  specialty PRTF will be restricted to members who meet the medical necessity
				  criteria at OAC
				  317:30-5-95.29 and OAC
				  317:30-5-95.30 for the respective
				  level of care and meet the additional criteria found in the Behavioral Health
				  Services Medical Necessity Criteria Manual, available on OHCA's website,
www.oklahoma.gov/ohca
.
(j) Non-authorized inpatient psychiatric
				  services will not be SoonerCare compensable.
(k) For out-of-state placement policy, refer
				  to OAC 317:30-3-89 through
				  317:30-3-92. A prime
				  consideration for placements will be proximity to the family or guardian in
				  order to involve the family or guardian in active treatment, including
				  discharge and reintegration planning. Out-of-state facilities are responsible
				  for insuring appropriate medical care, as needed under SoonerCare provisions,
				  as part of the per-diem rate.
(l)
				  Reimbursement for inpatient psychiatric services in all psychiatric units of
				  general hospitals, psychiatric hospitals, and PRTFs are limited to the approved
				  length of stay. OHCA, or its designated agent, will approve lengths of stay
				  using the current OHCA Behavioral Health medical necessity criteria as
				  described in OAC
				  317:30-5-95.25 through OAC
				  317:30-5-95.30. The approved
				  length of stay applies to both facility and physician services.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 24 Ok Reg 2880, eff 7-1-07 (emergency); Amended
					 at 25 Ok Reg 1161, eff 5-25-08; Amended at 27 Ok Reg 2737, eff 7-20-10
					 (emergency); Amended at 28 Ok Reg 1452, eff 6-25-11; Amended at 29 Ok Reg 413,
					 eff 3-7-12 (emergency); Amended at 29 Ok Reg 1125, eff
					 6-25-12