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 317:30-5-57 - Notice of denial

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
It is the policy and intent 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 OHCA, or its designated agent, upon their initial
				  review determines the admission should be denied, a notice is sent to the
				  facility and the attending physician(s) advising them of the decision. This
				  notice also advises that a reconsideration request may be submitted within 60
				  days.
(b)
Reconsideration
				  request.
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. 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 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.
(c)
Reconsideration request not made.
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.
(d)
Patient liability.
If an
				  OHCA, or its designated agent, review results of a 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.
(1) If a hospital or physician believes that
				  an acute care hospital admission or continued stay is not medically necessary
				  and thus not compensable but the member insists on treatment, the member should
				  be informed in writing that he/she will be personally responsible for all
				  charges.
(2) If a claim is filed
				  and paid and the service is later denied the member is not
				  responsible.