Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-361 - Billing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Encounters.
Payment is made for one (1) encounter per member per
				  day. Encounters with more than one (1) health professional and multiple
				  encounters with the same health professional that takes place on the same day
				  and a single location, constitute a single visit except when the member, after
				  the first encounter, suffers illness or injury requiring additional diagnosis
				  or treatment. Medical review will be required for additional visits for
				  children. Payment is also limited to four (4) visits per member per month for
				  adults. This limit may be exceeded if the SoonerCare Choice member has elected
				  the RHC as his/her/their Patient Centered Medical Home/Primary Care Provider.
				  RHCs must bill the combined fees of all "core" services provided during an
				  encounter on the appropriate claim form. Claims must include reasonable and
				  customary charges.
(1)
RHC.
The
				  appropriate revenue code is required. No HCPCS or CPT code is
				  required.
(2)
Mental
				  health.
Mental health services must include a revenue code and a HCPCS
				  code.
(3)
Obstetrical
				  care.
The appropriate revenue code and HCPCS code are required. The date
				  the member is first seen is required. The primary pregnancy diagnosis code is
				  also required. Secondary diagnosis codes are used to describe complications of
				  pregnancy. Delivery must be billed by the independent practitioner who has a
				  contract with the OHCA.
(4)
Family planning.
Family planning encounters require a revenue
				  code, HCPCS code, and a family planning diagnosis.
(5)
EPSDT screening.
EPSDT
				  screenings must be billed by the attending provider using the appropriate
				  Preventative Medicine procedure code from the CPT Manual. Payment is made
				  directly to the RHC on an encounter basis for on-site dental services by a
				  licensed dentist for members under the age of twenty-one (21).
(6)
Dental.
Dental services for
				  children must be billed on the appropriate dental claim form.
(A)
EPSDT dental screening.
An
				  EPSDT dental screening includes oral examination, prophylaxis and fluoride
				  treatment, charting of needed treatment, and, if necessary, x-rays (including
				  two bite wing films). This service must be filed on claim form ADM-36-D for
				  EPSDT reporting purposes.
(B)
Dental encounter.
A dental encounter consists of all dental
				  treatment other than a dental screening. This service must be billed on the
				  ADM-36-D.
(7)
Visual analysis.
Visual analysis services for a child with
				  glasses, or a child who needs glasses, or a medical eye exam. This includes the
				  refraction and medical eye health evaluation. Visual analysis services are
				  billed using the appropriate revenue code and a HCPCS code. Payment is made
				  directly to the RHC on an encounter basis for on-site optometric services by a
				  licensed optometrist for members under the age of twenty-one (21).