reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-60 - General program exclusions - children

Current through Vol. 41, No. 20, July 1, 2024
(a) The following are excluded from
				  SoonerCare coverage for children:
(1)
				  Inpatient admission for diagnostic studies that could be performed on an
				  outpatient basis.
(2) Services or
				  any expense incurred for cosmetic surgery unless the physician certifies the
				  procedure emotionally necessary.
(3) Services of two(2) physicians for the
				  same type of service to the same member on the same day, except when
				  supplemental skills are required and different specialties are involved.
(4) Pre-operative care within
				  twenty-four (24) hours of the day of admission for surgery and routine
				  post-operative care as defined under the global surgery guidelines promulgated
				  by Current Procedural Terminology (CPT) and the Centers for Medicare and
				  Medicaid Services (CMS).
(5)
				  Sterilization of members who are under twenty-one (21) years of age, mentally
				  incompetent, or institutionalized or reversal of sterilization procedures for
				  the purposes of conception.
(6)
				  Non-therapeutic hysterectomies.
(7)
				  Induced abortions, except when certified in writing by a physician that the
				  abortion was 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, or that the pregnancy is the result of an act of rape or incest.
				  [See Oklahoma Administrative Code (OAC)
				  317:30-5-6 or
				  317:30-5-50] .
(8) Medical services considered
				  experimental or investigational. For more information regarding experimental or
				  investigational including clinical trials, see OAC 317:30-3-57.1.
(9) Services of a Certified Surgical
				  Assistant.
(10) Services of a
				  Chiropractor.
(11) More than one(1)
				  inpatient visit per day per physician.
(12) Payment to the same physician for both
				  an outpatient visit and admission to hospital on the same date.
(13) Physician services which are
				  administrative in nature and not a direct service to the member including such
				  items as quality assurance, utilization review, treatment staffing, tumor board
				  review or multidisciplinary opinion, dictation, and similar functions.
(14) Payment for the services of
				  social workers, licensed family counselors, registered nurses or other
				  ancillary staff, except as specifically set out in Oklahoma Health Care
				  Authority (OHCA) rules.
(15) Direct
				  payment to perfusionist as this is considered part of the hospital
				  reimbursement.
(16) Charges for
				  completion of insurance forms, abstracts, narrative reports or telephone calls.
(17) Mileage.
(18) A routine hospital visit on date of
				  discharge unless the member expired.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-61 - Self-Directed Services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Agency
				  Model.
The OHCA Self-Direction Model is an overarching set of guidelines
				  to standardize policy for all self-directed service programs operated through
				  the SoonerCare program. The following rules set forth minimum requirements to
				  which all self-directed service programs must adhere. As the infrastructure for
				  new or renewing self-direction programs is developed, the following elements
				  will serve as a template for the programs to follow.
(b)
Definitions.
(1)
"Financial Management
				  Service"
(FMS) is defined as a fiscal intermediary that provides at a
				  minimum, accounting, billing and payroll services on behalf of the member, for
				  reimbursement through the OHCA.
(2)
"Program"
is defined as a set of benefits offered to a specific
				  population of SoonerCare members (the program can be operated by the OHCA or
				  another agency partner).
(3)
"Rendering provider"
is defined as the actual deliverer of
				  allowable goods or services.
(4)
"Self-Direction"
is defined as a method of service delivery that
				  allows members to determine what supports and services they need to live
				  successfully in a home and community based setting.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-62 - Provider Preventable Conditions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following words and terms, when used in this
				  Section, have the following meaning, unless the context clearly indicates
				  otherwise.
(1)
"Health care-acquired
				  conditions (HCAC)"
means a condition occurring in any inpatient hospital
				  setting, (identified as a hospital acquired condition by federal regulation and
				  Medicare; other than deep vein thrombosis/pulmonary embolism as related to a
				  total knee replacement or hip replacement surgery in pediatric and obstetric
				  patients.) Medicare's list of hospital acquired conditions is also available
				  at:
				  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.
(2)
"National Quality Forum
				  (NQF)"
means the independent, nonpartisan organization tasked with
				  devising a national strategy to set standards for quality improvement and
				  reporting in the healthcare industry.
(3)
"Other provider preventable
				  conditions (OPPC)"
means the list of serious reportable events in health
				  care as identified by this Section and published by the NQF.
(4)
"Present on admission (POA)
				  indicator"
means a status code the hospital uses on an inpatient claim
				  that indicates if a condition was present at the time the order for inpatient
				  admission occurs.
(5)
"Provider preventable condition (PPC)"
means a condition that
				  meets the definition of a "health care-acquired condition" or an "other
				  provider-preventable condition" as defined in this Section.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-62 - Serious reportable events - never events

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following
				  words and terms, when used in this Section, have the following meaning, unless
				  the context clearly indicates otherwise.
(1)
"Surgical and other invasive procedures"
are defined as operative
				  procedures in which skin or mucous membranes and connective tissues are incised
				  or an instrument is introduced through a natural body orifice. Invasive
				  procedures include a range of procedures from minimally invasive dermatological
				  procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to
				  extensive multi-organ transplantation. They include all procedures described by
				  the codes in the surgery section of the Current Procedural Terminology (CPT)
				  and other invasive procedures such as percutaneous transluminal angioplasty and
				  cardiac catheterization. They include minimally invasive procedures involving
				  biopsies or placement of probes or catheters requiring the entry into a body
				  cavity through a needle or trocar. They do not include use of instruments such
				  as otoscopes for examinations or very minor procedures such as drawing
				  blood.
(2) A surgical or other
				  invasive procedure is considered to be the wrong procedure if it is not
				  consistent with the correctly documented informed consent for that
				  member.
(3) A surgical or other
				  invasive procedure is considered to have been performed on the wrong body part
				  if it is not consistent with the correctly documented informed consent for that
				  member including surgery on the right body part, but on the wrong location on
				  the body; for example, left versus right (appendages and/or organs), or at the
				  wrong level (spine).
(4) A surgical
				  or other invasive procedure is considered to have been performed on the wrong
				  member if that procedure is not consistent with the correctly documented
				  informed consent for that member.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-63 - Hospital acquired conditions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage.
The Oklahoma Health Care Authority (OHCA) will no longer
				  reimburse the extra cost of treating certain categories of conditions that
				  occur while a member is in the hospital. For discharges, hospitals will not
				  receive additional payment for cases in which one of the selected conditions
				  was not present on admission. The claim will be grouped to a DRG as if the
				  diagnosis was not present on the claim. The selected conditions that OHCA
				  recognizes are those conditions identified as non-payable by Medicare. OHCA may
				  revise through addition or deletion the selected conditions at any time during
				  the fiscal year. The following is a complete list of the hospital acquired
				  conditions (HACs) currently recognized by OHCA:
(1) Foreign Object Retained After
				  Surgery
(2) Air Embolism
(3) Blood Incompatibility
(4) Pressure Ulcer Stages III &
				  IV
(5) Falls and Trauma
(A) Fracture
(B) Dislocation
(C) Intracranial Injury
(D) Crushing Injury
(E) Burn
(F) Electric Shock
(6) Catheter-Associated Urinary Tract
				  Infection
(7) Vascular
				  Catheter-Associated Infection
(8)
				  Manifestations of Poor Glycemic Control
(A)
				  Diabetic Ketoacidosis
(B)
				  Nonketotic Hyperosmolar Coma
(C)
				  Hypoglycemic Coma
(D) Secondary
				  Diabetes with Ketoacidosis
(E)
				  Secondary Diabetes with Hyperosmolarity
(9) Surgical Site Infection Following:
(A) Coronary Artery Bypass Graft-
				  Mediastinitis
(B) Bariatric Surgery
(i) Laparoscopic Gastric Bypass
(ii) Gastroenterostomy
(iii) Laparoscopic Gastric Restrictive
				  Surgery
(C) Orthopedic
				  Procedures
(i) Spine
(ii) Neck
(iii) Shoulder
(iv) Elbow
(10) Deep Vein Thrombosis and Pulmonary
				  Embolism
(A) Total Knee Replacement
(B) Hip Replacement
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-64 - Payment for lodging and meals [Renumbered]

Current through Vol. 41, No. 20, July 1, 2024
Added at 30 Ok Reg 1129, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.1 - Minimum required screenings [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.2 - Periodicity schedule

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) requires that
					 physicians providing reimbursable Early and Periodic Screening, Diagnosis and
					 Treatment (EPSDT) screens adopt and utilize the guidelines established by the
					 American Academy of Pediatrics' Bright Futures' periodicity schedule.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.3 - Initial screening examination

Current through Vol. 41, No. 20, July 1, 2024
An initial EPSDT screening may be requested by an eligible
					 individual at any time and must be provided without regard to whether the
					 individual's age coincides with the established periodicity
					 schedule.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.4 - Screening components

Current through Vol. 41, No. 20, July 1, 2024
Comprehensive Early and Periodic Screening, Diagnosis and
					 Treatment (EPSDT) screenings are performed by, or under the supervision of, a
					 SoonerCare physician or other SoonerCare practitioner. SoonerCare physicians
					 are defined as all licensed allopathic and osteopathic physicians in accordance
					 with the rules and regulations covering the Oklahoma Health Care Authority's
					 (OHCA) SoonerCare program. Other SoonerCare practitioners are defined as all
					 contracted physician assistants and advanced practice registered nurses in
					 accordance with the rules and regulations covering the OHCA's SoonerCare
					 program. At a minimum, screening examinations must include, but not be limited
					 to, the following components:
(1)
Comprehensive health and developmental history.
Health and
				  developmental history information may be obtained from the parent or other
				  responsible adult who is familiar with the member's history and include an
				  assessment of both physical and mental health development. Coupled with the
				  physical examination, this includes:
(A)
Developmental assessment.
Developmental assessment includes a
				  range of activities to determine whether an individual's developmental
				  processes fall within a normal range of achievement according to age group and
				  cultural background. Screening for development assessment is a part of every
				  routine, initial and periodic screening examination. Acquire information on the
				  member's usual functioning as reported by the member, teacher, health
				  professional or other familiar person. Review developmental progress as a
				  component of overall health and well-being given the member's age and culture.
				  As appropriate, assess the following elements:
(i) Gross and fine motor
				  development;
(ii) Communication
				  skills, language and speech development;
(iii) Self-help, self-care skills;
(iv) Social-emotional development;
(v) Cognitive skills;
(vi) Visual-motor skills;
(vii) Learning disabilities;
(viii) Psychological/psychiatric
				  problems;
(ix) Peer relations;
				  and
(x) Vocational
				  skills.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.5 - Diagnosis and treatment

Current through Vol. 41, No. 20, July 1, 2024
When a screening indicates the need for further evaluation
					 of an individual's health, a referral for appropriate diagnostic studies or
					 treatment services must be provided without delay. Diagnostic services are
					 defined as those services necessary to fully evaluate defects, physical or
					 behavioral health illnesses or conditions discovered by the screening.
(1) Health care, treatment, or other measures
				  to correct or ameliorate defects, physical or mental illnesses or conditions
				  must also be provided and will be covered by the EPSDT/OHCA Child Health
				  Program as medically necessary. The defects, illnesses and conditions must have
				  been discovered during the screening or shown to have increased in severity.
(2) Services, deemed medically
				  necessary and allowable under federal Medicaid regulations, may be covered by
				  the EPSDT/OHCA Child Health program even though those services may not be part
				  of the Oklahoma Health Care Authority Medicaid program. However, such services
				  must be prior authorized and must be allowable under federal Medicaid
				  regulations.
(3) Federal Medicaid
				  regulations also require the State to make the determination as to whether the
				  service is medically necessary and do not require the provision of any items or
				  services that the State determines are not safe and effective or which are
				  considered experimental. For more information regarding experimental or
				  investigational including clinical trials, see Oklahoma Administrative Code
				  317:30-3-57.1.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.6 - Documentation of Services

Current through Vol. 41, No. 20, July 1, 2024
Records for Early and Periodic Screening, Diagnosis and
					 Treatment (EPSDT) screens must contain adequate documentation of services
					 rendered. Such documentation must include the physicians' signature or
					 identifiable initials for every prescription or treatment. Documentation of
					 records may be completed manually or electronically in accordance with
					 guidelines found at OAC
					 317:30-3-15.
					 Each required element of the age specific screening must be documented with a
					 description of any noted problem, anomaly or concern. In addition, a plan for
					 following necessary diagnostic evaluations, procedures and treatments, must be
					 documented.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.7 - Vision services

Current through Vol. 41, No. 20, July 1, 2024
Children and adolescents should receive periodic eye and
					 vision examinations to diagnose and treat any eye disease in its early stages
					 in order to prevent or minimize vision loss and maximize visual
					 abilities.
(1) At a minimum, vision
				  services include diagnosis and treatment for defects in vision, including
				  eyeglasses once each twelve (12) months. In addition, payment is made for
				  glasses for members with congenital aphakia or following cataract removal
				  (refer to OAC
				  317:30-5-2(b)(5)
				  for amount, duration, and scope). Payment is limited to only two (2) glasses
				  per year for a member. Any glasses beyond the two (2) glasses limit must be
				  prior authorized and determined to be medically necessary (refer to
				  317:30-5-432.1
				  for more information on corrective lenses and optical supplies).
(2) The OHCA recommends that physicians adopt
				  and utilize the American Optometric Association standards for vision screenings
				  and examinations.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.8 - Dental services

Current through Vol. 41, No. 20, July 1, 2024
(a) At a minimum,
				  dental services include relief of pain and infection; limited restoration of
				  teeth and maintenance of dental health; and oral prophylaxis every six (6)
				  months. Dental care includes emergency and preventive services and therapeutic
				  services for dental disease which, if left untreated, may become acute dental
				  problems or may cause irreversible damage to the teeth or supporting
				  structures. Other dental services include inpatient services in an eligible
				  participating hospital, and amalgam and composite restorations, pulpotomies,
				  chrome steel crowns, anterior root canals, pulpectomies, band and loop space
				  maintainers, acrylic partial and lingual arch bars; other restoration, repair
				  and/or replacement of dental defects after the treatment plan submitted by a
				  dentist has been authorized [ refer to Oklahoma Administrative Code
				  317:30-5-696(2)
				  for amount, duration and scope].
(b) Dental screenings should begin at the
				  first sign of tooth eruption by the primary care provider and with each
				  subsequent visit to determine if the member needs a referral to a dental
				  provider. Dental examinations by a qualified dental provider should begin by
				  age one (1)(unless otherwise indicated) and every six (6) months to one (1)
				  year thereafter. Additionally, members should be seen for prophylaxis once
				  every six (6) months, if indicated by risk assessment. All other dental
				  services for relief of pain and infection, restoration of teeth and maintenance
				  of dental health should occur as the provider deems necessary.
(c) Separate payment will be made to the
				  member's primary care provider for the application of fluoride varnish during
				  the course of a child-health screening for members ages six (6) months to sixty
				  (60) months. Reimbursement is limited to two applications per year.
Added at 23 Ok Reg
					 2463, eff 6-25-06; Amended at 28 Ok Reg 1419, eff
					 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.9 - Hearing services

Current through Vol. 41, No. 20, July 1, 2024
(a) At a minimum,
				  hearing services include hearing evaluation once every twelve (12) months,
				  hearing aid evaluation if indicated and purchase of a hearing aid when
				  prescribed by a state licensed audiologist who:
(1) holds a certificate of clinical
				  competence from the American Speech and Hearing Association of the American
				  Academy of Audiologists; or
(2) has
				  completed the equivalent educational requirements and work experience necessary
				  for the certificate; or
(3) has
				  completed the academic program and is acquiring supervised work experience
				  necessary for the certificate; and
(4) holds a contract with Oklahoma Health
				  Care Authority (OHCA) to perform such an evaluation and obtains prior
				  authorization for the evaluation.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.10 - Periodic and interperiodic screening examinations

Current through Vol. 41, No. 20, July 1, 2024
(a)
Periodic screening examination.
Periodic screenings must be provided in accordance with the recommended
				  American Academy of Pediatrics' Bright Futures' periodicity schedule following
				  the initial screening.
(b)
Interperiodic screening examination.
Interperiodic screenings must
				  be provided when medically necessary to determine the existence of suspected
				  physical or mental illnesses or conditions. This may include, but is not
				  limited to, physical, mental or dental conditions. The screening components
				  must include health and physical history, physical examination, assessment and
				  administration of necessary immunizations, check of nutritional status,
				  appropriate lab and x-ray and anticipatory guidance. The determination of
				  whether an interperiodic screen is medically necessary may be made by a health,
				  developmental or educational professional who comes into contact with the
				  member outside of the formal health care system. Claims for interperiodic
				  screenings must be billed under the appropriate Current Procedural Terminology
				  codes on form HCFA-1500 for services that are determined medically
				  necessary.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.11 - Partial screening examination

Current through Vol. 41, No. 20, July 1, 2024
A partial screening may be paid if the provider cannot
					 provide all of the minimum components of the screening.
Added at 23 Ok Reg
					 2463, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 4 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM/CHILD-HEALTH SERVICES › Section 317:30-3-65.12 - Applied behavior analysis (ABA) services

Current through Vol. 41, No. 20, July 1, 2024
ABA services are provided under the EPSDT benefit. Refer
					 to OAC 317:30-5-310 through 317:30-5-316 for coverage, provider and program
					 requirements, and reimbursement methodology.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-70 - Categorical relationship [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 18 Ok Reg 2557,
						eff 6-25-01 ; Amended at 20 Ok Reg 2762, eff 7-1-03 (emergency) ; Amended at 21
						Ok Reg 2176, eff 6-25-04 ; Revoked at 30 Ok Reg 1131, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-71 - Financial need [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 16 Ok Reg 685,
						eff 12-28-98 (emergency) ; Amended at 16 Ok Reg 1429, eff 5-27-99 ; Amended at
						20 Ok Reg 2762, eff 7-1-03 (emergency) ; Amended at 21 Ok Reg 2176, eff 6-25-04
						; Revoked at 30 Ok Reg 1131, eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-72 - Spenddown [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 20 Ok Reg 2762, eff 7-1-03 (emergency); Revoked at 21 Ok
					 Reg 2176, eff 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-73 - Persons eligible for medical assistance [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 16 Ok Reg 685, eff 12-28-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99; Amended at 19 Ok Reg 63, eff 9-1-01; Amended at 19 Ok
					 Reg 2127, eff 6-27-02; Revoked at 21 Ok Reg 2201, eff
					 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-74 - Persons not eligible for medical assistance [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 23 Ok Reg 263, eff 9-1-05 (emergency); Revoked at 23 Ok Reg
					 1352, eff 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-75 - Person 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 ; Amended at 18 Ok Reg 2557,
						eff 6-25-01 ; Revoked at 30 Ok Reg 1131, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-76 - Retroactive eligibility [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 21 Ok Reg 2201, eff 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-77 - Notification of needed medical services [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 21 Ok Reg 2201,
						eff 6-25-04 ; Revoked at 30 Ok Reg 1131, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-78 - Request for prior authorization for dental services [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 20 Ok Reg 1924, eff 6-26-03; Amended at 23 Ok Reg 2489, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-79 - Hearing appliance prescription and supplier request for prior authorization [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 14 Ok Reg 524, eff 12-24-96 (emergency); Amended at 14 Ok
					 Reg 1785, eff 5-27-97; Amended at 16 Ok Reg 1927, eff
					 6-11-99
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-80 - Physician's prescription for appliances, prostheses, and/or medical equipment and medical suppliers request for prior authorization [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 18 Ok Reg 477, eff 1-1-01 (emergency); Amended at 18 Ok Reg
					 1130, eff 5-11-01; Revoked at 26 Ok Reg 3028, eff 9-1-09 (emergency); Amended
					 at 27 Ok Reg 936, eff 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-81 - Notification of eligibility status for assistance (adults) [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 30 Ok Reg 1131,
						eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-82 - Prior authorization for services to individuals under 21 years of age [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 15 Ok Reg 4182, eff 8-5-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99; Amended at 17 Ok Reg 805, eff 7-16-99 (emergency);
					 Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 18 Ok Reg 477, eff 1-1-01
					 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 20 Ok Reg 1924,
					 eff 6-26-03
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-83 - Prior authorization for services to adults [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 15 Ok Reg 4182, eff 8-5-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-84 - Catastrophic illness [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 14 Ok Reg 749, eff 12-24-96 (emergency); Amended at 14 Ok
					 Reg 1785, eff 5-27-97; Revoked at 20 Ok Reg 2762, eff 7-1-03 (emergency);
					 Revoked at 21 Ok Reg 2176, eff 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-85 - Citizenship and alienage [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 24 Ok Reg 2068,
						eff 6-25-07 ; Revoked at 30 Ok Reg 1131, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-86 - Residency [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 30 Ok Reg 1131,
						eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-87 - Presumptive eligibility [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 30 Ok Reg 1131,
						eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 5 - ELIGIBILITY [REVOKED] › Section 317:30-3-88 - Medical identification card [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 16 Ok Reg 685, eff 12-28-98 (emergency); Amended at 16 Ok
					 Reg 2733, eff 3-15-99 (emergency); Amended at 16 Ok Reg 1429, eff
					 5-27-99
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 6 - OUT-OF-STATE SERVICES › Section 317:30-3-89 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms used in this Part shall have
					 the following meaning, unless the context clearly indicates otherwise:
"Emergency"
means a serious situation or
					 occurrence that happens unexpectedly and demands immediate action such as a
					 medical condition manifesting itself by acute symptoms of sufficient severity
					 (including severe pain) such that the absence of immediate medical attention
					 could reasonably be expected, by a reasonable and prudent layperson, to result
					 in placing the member's health in serious jeopardy, serious impairment to
					 bodily function, or serious dysfunction of any bodily organ or part.
"Out-of-state provider"
means a provider
					 contracted with SoonerCare in accordance with Oklahoma Administrative Code
					 (OAC) 317:30-3-2, if:
(A) The physical address where services are or will be
					 rendered is located outside the Oklahoma border and within the United States;
					 or
(B) The physical address where services are or will be
					 rendered is located within the Oklahoma border, but:
(i) The out-of-state provider maintains all member and/or
					 billing records outside the Oklahoma border; and
(ii) The out-of-state provider is unable to produce the
					 originals or exact copies of the member and/or billing records from the
					 location in Oklahoma where services are rendered.
"Temporary"
means lasting for a limited period
					 of time, such as when a member is on vacation, but does not include situations
					 in which a SoonerCare member leaves Oklahoma for the purpose of receiving
					 medical care and treatment.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 6 - OUT-OF-STATE SERVICES › Section 317:30-3-90 - Out-of-state services

Current through Vol. 41, No. 20, July 1, 2024
(a) Consistent with
				  Section 431.52 of Title 42 of the Code of
				  Federal Regulations (C.F.R.), an eligible SoonerCare member who is a resident
				  of Oklahoma but who is temporarily out of state, may receive services from an
				  out-of-state provider to the same extent that he or she would receive such
				  services in Oklahoma, if:
(1) Medical
				  services are needed for a medical emergency, as determined by the attending
				  physician or other provider (M.D., D.O., P.A., or A.P.R.N), or a dentist
				  [Doctor of Dental Surgery (DDS), or Doctor of Medicine in Dentistry (DMD)]. For
				  any provider, who is not contracted at the time the services are provided,
				  documentation as requested from the Oklahoma Health Care Authority (OHCA) of
				  the emergency must be submitted, including, but not limited to, emergency room
				  reports, medical histories, discharge summaries, and all other relevant medical
				  reports.
(2) Medical services are
				  needed and the member's health would be endangered if he or she were required
				  to return to Oklahoma for medical care and treatment, as determined by the
				  attending physician or other provider (M.D., D.O., P.A., or A.P.R.N), or a
				  dentist [Doctor of Dental Surgery (DDS), or Doctor of Medicine in Dentistry
				  (DMD)]. For any provider, who is not contracted at the time the services are
				  provided, documentation of the nature and possible extent of the endangerment
				  must be submitted as requested from the OHCA.
(3) The Oklahoma Health Care Authority's
				  (OHCA) Chief Medical Officer (CMO), or his or her designee, determines, on the
				  basis of medical advice, that the needed medical services, or necessary
				  supplemental resources, are more readily available in the state where the
				  member is located at the time of needing medical treatment. Prior authorization
				  must be obtained from the OHCA's CMO, or his or her designee, before the
				  services are rendered.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 6 - OUT-OF-STATE SERVICES › Section 317:30-3-91 - Reimbursement of services rendered by out-of-state providers

Current through Vol. 41, No. 20, July 1, 2024
(a) Before an out-of-state provider can
				  receive reimbursement, it shall contract with SoonerCare and be subject to
				  enrollment, including, but not limited to, providing information requested by
				  the Oklahoma Health Care Authority (OHCA) such as name, address, Social
				  Security Number or Tax Identification Number, and verification of licensure and
				  insurance. Out-of-state providers are also subject to the same screening rules,
				  policies, and procedures as in-state providers, including, but not limited to
				  Oklahoma Administrative Code (OAC)
				  317:30-3-2,
				  and
				  317:30-3-19.3
				  through
				  317:30-3-19.4.
				  Once the OHCA approves enrollment, the provider will receive a SoonerCare
				  provider number that will allow claims to be processed.
(b) While the member's physician may suggest
				  where the member be sent, the OHCA's Chief Medical Officer (CMO), or his or her
				  designee, is responsible for making the final determination based on the most
				  cost effective institution and treatment consistent with the recognized
				  standards of care. Reimbursement for services rendered by out-of-state
				  providers shall be as follows:
(1)
				  Reimbursement for inpatient hospital services shall be made in accordance with
				  OAC
				  317:30-5-47.
(2) Reimbursement for outpatient
				  hospital services shall be made in accordance with OAC
				  317:30-5-42.14
				  and
				  317:30-5-566.
(3) Reimbursement for physician
				  services shall be the lower of the SoonerCare maximum allowable fee as of the
				  date the service was rendered, available at
www.okhca.org
(SoonerCare Fee Schedules), or the
				  provider's actual charge. Exceptions to the above reimbursement method are
				  payments for outpatient clinical diagnostic laboratory tests performed by a
				  physician or independent laboratory. These tests will be reimbursed at the
				  lower of the provider's actual charge or a rate of reimbursement equal to the
				  rate paid by Medicare.
(4) Unless
				  authorized by the Oklahoma State Plan, any reimbursement shall not exceed the
				  rate paid by Medicare.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 6 - OUT-OF-STATE SERVICES › Section 317:30-3-92 - Lodging and meals services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Requests for lodging and meals services.
(1) Requests for lodging and meals services
				  shall derive from the treating facility or the member. All requests shall be
				  submitted at least three (3) business days prior to check-in, with exceptions
				  made only in emergency situations. Requests will include, but are not limited
				  to, the following information:
(A) SoonerCare
				  member information:
(i) Name;
(ii) SoonerCare ID number;
(iii) Address;
(iv) Member diagnosis;
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 317:30-5-1 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
To allow patients free choice of physicians, the Oklahoma
					 Health Care Authority (OHCA) recognizes all licensed medical and osteopathic
					 physicians as being eligible to receive payment for compensable medical
					 services rendered in behalf of a person eligible for such care in accordance
					 with the rules and regulations covering the Authority's medical care programs.
					 Payment will be made to fully licensed physicians who are participating in
					 medical training programs as students, interns, residents, or fellows, or in
					 any other capacity in training for services outside the training setting and
					 are not in a duplicative billing situation. In addition, payment will be made
					 to the employing facility for services provided by physicians who meet all
					 requirements for employment by the Federal Government as a physician and are
					 employed by the Federal Government in an IHS facility or who provide services
					 in a 638 Tribal Facility. Payment will not be made to a provider who has been
					 suspended or terminated from participation in the program.
(1) Payment to physicians under SoonerCare is
				  made for services clearly identifiable as personally rendered services
				  performed on behalf of a specific patient. There are no exceptions to
				  personally rendered services unless specifically set out in coverage
				  guidelines.
(2) Payment is made to
				  the attending physician in a teaching medical facility for compensable services
				  when he/she signs as claimant, and renders personal and identifiable services
				  to the patient in conformity with Federal regulations.
(3) Payment is made to a physician for
				  medically directing the services of a Certified Registered Nurse Anesthetist
				  (CRNA) at a rate of 50% of the physician allowable for anesthesia
				  services.
(4) Payment is made to a
				  physician for the direct supervision of an Anesthesiologist Assistant (AA) at a
				  rate of 50% of the physician allowable for anesthesia services. Direct
				  supervision means the on-site, personal supervision by an anesthesiologist who
				  is present in the office, or is present in the surgical or obstetrical suite
				  when the procedure is being performed and who is in all instances immediately
				  available to provide assistance and direction to the AA while anesthesia
				  services are being performed.
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 15 Ok Reg 1083, eff 12-15-97 (emergency); Amended at 15 Ok
					 Reg 1528, eff 5-11-98; Amended at 26 Ok Reg 1759, eff 7-1-09 (emergency);
					 Amended at 27 Ok Reg 937, eff 5-13-10
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 317:30-5-3 - Documentation of services

Current through Vol. 41, No. 20, July 1, 2024
(a) Records in a
				  physician's office or a medical institution (hospital, nursing home or other
				  medical facility), must contain adequate documentation of services rendered.
				  Such documentation must include the physician's signature or identifiable
				  initials in relation to every patient visit, every prescription, or treatment.
				  In verifying the accuracy of claims for procedures which are reimbursed on a
				  time frame basis, it will be necessary that documentation be placed in the
				  patient's chart as to the beginning and ending times for the service
				  claimed.
(b) Providers must adhere
				  to signature requirements found at OAC
				  317:30-3-30.
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