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 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-25 - Crossovers (deductibles, coinsurance, and copays)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medicare Part A.
Payment is
				  made for Medicare deductibles, coinsurance, and copays on behalf of eligible
				  individuals according to the methodology outlined in the Oklahoma Medicaid
				  State Plan.
(b)
Medicare Part
				  B.
Payment is made for Medicare deductibles, coinsurance, and copays on
				  behalf of eligible individualsaccording to the methodology outlined in the
				  Oklahoma Medicaid State Plan.
(c)
Medicare Part C (Medicare Advantage Plans).
Payment is made for
				  Medicare deductibles, coinsurance, and copays on behalf of eligible individuals
				  according to the methodology outlined in the Oklahoma Medicaid State
				  Plan.
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 107,
						eff 11-1-00 (emergency) ; Amended at 18 Ok Reg 1130, eff 5-11-01 ; Amended at
						19 Ok Reg 2922, eff 7-1-02 (emergency) ; Amended at 20 Ok Reg 1193, eff 5-27-03
						; Amended at 21 Ok Reg 2175, eff 6-25-04 ; Amended at 23 Ok Reg 2460, eff
						6-25-06 ; Amended at 26 Ok Reg 248, eff 12-1-08 (emergency) ; Amended at 26 Ok
						Reg 1052, eff 5-11-09 ; Amended at 30 Ok Reg 371, eff 1-28-13 (emergency) ;
						Amended at 30 Ok Reg 1123, 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 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-26 - Medicare Physician Payment Reform methodology [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 2175, 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 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-27 - Telehealth

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)
"Remote patient
				  monitoring"
means the use of digital technologies to collect medical and
				  other forms of health data (e.g., vital signs, weight, blood pressure, blood
				  sugar) from individuals in one (1) location and electronically transmit that
				  information securely to health care providers in a different location for
				  assessment and recommendations.
(2)
"School-based services"
means medically necessary health-related
				  and rehabilitative services that are provided by a qualified school provider to
				  a student under the age of twenty-one (21), pursuant to an Individualized
				  Education Program (IEP), in accordance with the Individuals with Disabilities
				  Education Act. See Oklahoma Administrative Code (OAC)
				  317:30-5-1020.
(3)
"Store and forward
				  technologies"
means the transmission of a patient's medical information
				  from an originating site to the health care provider at the distant site;
				  provided, photographs visualized by a telecommunications system shall be
				  specific to the patient's medical condition and adequate for furnishing or
				  confirming a diagnosis or treatment plan. Store and forward technologies shall
				  not include consultations provided by telephone audio-only communication,
				  electronic mail, text message, instant messaging conversation, website
				  questionnaire, nonsecure video conference, or facsimile transmission.
(4)
"Telehealth"
means the
				  practice of health care delivery, diagnosis, consultation, evaluation and
				  treatment, transfer of medical data or exchange of medical education
				  information by means of a two-way, real-time interactive communication, not to
				  exclude store and forward technologies, between a patient and a healthcare
				  provider with access to and reviewing the patient's relevant clinical
				  information prior to the telemedicine visit. Telehealth shall not include
				  consultations provided by telephone audio-only communication, electronic mail,
				  text message, instant messaging conversation, website questionnaire, nonsecure
				  video conference, or facsimile transmission. For audio-only health service
				  delivery, see OAC
				  317:30-3-27.1.
(5)
"Telehealth medical service"
means, for the purpose of the notification requirements of OAC
				  317:30-3-27(d)(2),
				  telehealth services that expressly do not include physical therapy,
				  occupational therapy, and/or speech and hearing services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-27 - Telehealth

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)
"Remote patient
				  monitoring"
means the use of digital technologies to collect medical and
				  other forms of health data (e.g. vital signs, weight, blood pressure, blood
				  sugar) from individuals in one (1) location and electronically transmit that
				  information securely to health care providers in a different location for
				  assessment and recommendations.
(2)
"School-based services"
means medically necessary health-related and rehabilitative services that are
				  provided by a qualified school provider to a student under the age of
				  twenty-one (21), pursuant to an Individualized Education Program (IEP), in
				  accordance with the Individuals with Disabilities Education Act. See Oklahoma
				  Administrative Code (OAC)
				  317:30-5-1020.
(3)
"Store and forward
				  technologies"
means the transmission of a patient's medical information
				  from an originating site to the health care provider at the distant site;
				  provided, photographs visualized by a telecommunications system shall be
				  specific to the patient's medical condition and adequate for furnishing or
				  confirming a diagnosis or treatment plan. Store and forward technologies shall
				  not include consultations provided by telephone audio-only communication,
				  electronic mail, text message, instant messaging conversation, website
				  questionnaire, nonsecure video conference, or facsimile transmission.
(4)
"Telehealth"
means the practice of health care delivery, diagnosis, consultation, evaluation
				  and treatment, transfer of medical data or exchange of medical education
				  information by means of a two-way, real-time interactive communication, not to
				  exclude store and forward technologies, between a patient and a health care
				  provider with access to and reviewing the patient's relevant clinical
				  information prior to the telemedicine visit. Telehealth shall not include
				  consultations provided by telephone audio-only communication, electronic mail,
				  text message, instant messaging conversation, website questionnaire, nonsecure
				  video conference, or facsimile transmission.
(5)
"Telehealth medical service"
means, for the purpose of the notification requirements of OAC
				  317:30-3-27(d)(2), telehealth services that expressly do not include physical
				  therapy, occupational therapy, and/or speech and hearing services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-27.1 - Audio-only health service delivery

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definition.
"Audio-only health service delivery" means the
				  delivery of healthcare services through the use of audio-only
				  telecommunications, permitting real-time communication between a patient and
				  the provider, for the purpose of diagnosis, consultation, and/or treatment.
				  Audio-only health service delivery does not include the use of facsimile,
				  email, or health care services that are customarily delivered by audio-only
				  telecommunications and not billed as separate services by the provider, such as
				  the sharing of laboratory results. This definition includes health services
				  delivered via audio-only when audio-visual is unavailable or when a member
				  chooses audio-only.
(b)
Purpose.
Health services delivered via audio-only
				  telecommunications are intended to improve access to healthcare services, while
				  complying with all applicable state and federal laws and regulations.
				  Audio-only telecommunications is an option for the delivery of certain covered
				  services and is not an expansion of SoonerCare-covered services.
(c)
Applicability and scope.
The
				  applicability and scope of this section of policy is outlined below:
(1) Health service delivery via audio-only
				  telecommunications is applicable to medically necessary covered primary care
				  and other approved health services. Refer to the Oklahoma Health Care Authority
				  (OHCA) website,
www.okhca.org
, for a
				  complete list of the SoonerCare-reimbursable audio-only health services
				  codes.
(2) If there are
				  technological difficulties in performing medical assessment through audio-only
				  telecommunications, then hands-on-assessment and/or in-person care must be
				  provided for the member. Any service delivered using audio-only
				  telecommunications must be appropriate for audio-only delivery and be of the
				  same quality and otherwise on par with the same service delivered in
				  person.
(3) Confidentiality and
				  security of protected health information in accordance with applicable state
				  and federal law, including, but not limited to, 42 Code of Federal Regulations
				  (CFR) Part 2, 45 CFR Parts
				  160 and
				  164, and
				  43A Oklahoma Statutes (O.S.)
				  § 1-109, must be maintained in the delivery of health services by
				  audio-only telecommunications.
(4)
				  For purposes of SoonerCare reimbursement, audio-only health service delivery is
				  the use of interactive audio technology for the purpose of diagnosis,
				  consultation, and/or treatment that occurs in real-time and when the member is
				  actively participating during the transmission.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-28 - Oklahoma Electronic Health Records Incentive Program

Current through Vol. 41, No. 20, July 1, 2024
(a)
Program.
The Oklahoma
				  Electronic Health Records (EHR) Incentive Program is authorized by the American
				  Recovery and Reinvestment Act of 2009. Under this program, SoonerCare providers
				  may qualify for incentive payments if they meet the eligibility guidelines in
				  this section and demonstrate they are engaged in efforts to adopt, implement,
				  upgrade, or meaningfully use certified EHR technology. The Oklahoma EHR
				  Incentive Program is governed by the policy in this section and the Electronic
				  Health Records Program Final Rule issued by the Center for Medicare and
				  Medicaid Services (CMS) in CMS-0033-F and Section 170 of Title 45 of the Code
				  of Federal Regulations (C.F.R.). Providers should also use the EHR program
				  manual as a reference for additional program details.
(b)
Eligible providers.
To
				  qualify for incentive payments, a provider must be an "eligible professional"
				  or an "eligible hospital." Providers who receive incentive payments must have
				  an existing Provider Agreement with the Oklahoma Health Care Authority (OHCA).
(1)
Eligible professionals.
An
				  eligible professional is defined as a physician, a physician assistant
				  practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center
				  (RHC) led by a physician assistant, a board certified pediatrician, a nurse
				  practitioner, a certified nurse midwife, or a dentist. OHCA will determine
				  eligibility based on the provider type, specialty associated with the provider
				  in the Medicaid Management Information System, and documentation.
(A) Eligible professionals may not be
				  hospital-based, unless they practice predominantly at an FQHC or RHC as defined
				  by the CMS final rule. A "hospital-based" professional furnishes ninety percent
				  (90%) or more of their SoonerCare-covered professional services during the
				  relevant EHR reporting period in a hospital setting, whether inpatient or
				  Emergency Room, through the use of the facilities and equipment of the
				  hospital. Specific exclusions to the "hospital-based" definition may be allowed
				  by federal law and are detailed in the Oklahoma EHR Incentive Program provider
				  manual.
(B) Eligible professionals
				  may not participate in both the Medicaid and Medicare EHR incentive payment
				  program during the same payment year.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-29 - Revisions of provider fee schedules

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority (OHCA)
				  reserves the right to review and/or update and adjust provider fee schedules.
				  Provider fee schedules will be reviewed annually and adjustments to the fee
				  schedules may be made at any time based on efficiency, budget considerations,
				  economy, and quality of care. The OHCA assures that all payments will be
				  sufficient to enlist enough providers so that care and services are available
				  under the State Plan at least to the extent that such care and services are
				  available to the general population in the geographic area. The OHCA may issue
				  revisions to provider fee schedules during the year that they are effective.
				  Providers will be notified of any revisions to the fee schedule and the
				  revision effective dates. Provider fee schedules, when reviewed and changed,
				  are posted to the OHCA's website in relation to the current State Fiscal Year.
				  The OHCA will adjust provider fee schedules to:
(1) comply with changes in state or federal
				  requirements;
(2) comply with
				  changes in nationally recognized coding systems, such as Healthcare Common
				  Procedure Coding System (HCPCS) and Current Procedural Terminology
				  (CPT);
(3) establish an initial
				  allowable amount for a new procedure based on information that was not
				  available when the fee schedule was established for the current year;
				  and
(4) adjust the allowable amount
				  when the OHCA determines that the current allowable amount is:
(A) not appropriate for the service provided;
				  or
(B) based on errors in data or
				  calculation.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-30 - Signature requirements

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  For medical review purposes, the Oklahoma Health Care Authority (OHCA) requires
				  that all services provided and/or ordered be authenticated by the author. The
				  method used shall be a handwritten signature, electronic signature, or
				  signature attestation statement. Stamped signatures are not acceptable.
				  Pursuant to federal and/or state law, there are some circumstances for which an
				  order does not need to be signed.
(1)
				  Facsimile of original written or electronic signatures are acceptable for the
				  certifications of terminal illness for hospice.
(2) Orders for clinical diagnostic tests are
				  not required to be signed. If the order for the clinical diagnostic test is
				  unsigned, there must be medical documentation by the treating physician that
				  he/she intended the clinical diagnostic test be performed. This documentation
				  showing the intent that the test be performed must be authenticated by the
				  author via a handwritten or electronic signature.
(3) Orders for outpatient prescription drugs
				  are not required to be signed. If the order for a prescription drug is
				  unsigned, there must be medical documentation by the treating physician that
				  he/she intended that the prescription drug be ordered. This documentation
				  showing the intent that the prescription drug be ordered must be authenticated
				  by the author via a handwritten or electronic signature.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-31 - Prior authorization for health care-related goods and services

Current through Vol. 41, No. 20, July 1, 2024
(a) Under the
				  SoonerCare program, there are health care-related goods and services that
				  require prior authorization (PA) by the Oklahoma Health Care Authority (OHCA).
				  PA is a process to determine if a prescribed good or service is medically
				  necessary; it is not, however, a guarantee of member eligibility or of
				  SoonerCare payment. All goods or services requiring PA will be authorized on
				  the basis of information submitted to OHCA, including:
(1) The relevant code, as is appropriate for
				  the good or service requested (for example, Current Procedural Terminology
				  (CPT) codes for services; Healthcare Common Procedure Coding System (HCPCS)
				  codes, for durable medical equipment; or National Drug Codes (NDC), for drugs);
				  and/or
(2) Any other information
				  required by OHCA, in the format as prescribed. The OHCA authorization file will
				  reflect the codes that have been authorized.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-32 - Retrospective review for payment for services to certain aliens

Current through Vol. 41, No. 20, July 1, 2024
Certain aliens are only eligible for emergency medical
					 services (Refer to OAC
					 317:35-5-25
					 ). Requests for alien services should be submitted to the local county Oklahoma
					 Department of Human Services (OKDHS) office on Form 08MA005E (MS-MA-5),
					 Notification of Needed Medical Services. OKDHS forwards the appropriate
					 paperwork to the Oklahoma Health Care Authority where the case undergoes
					 retrospective review for payment by medical staff. Retrospective review is a
					 process in which a claim and medical records are reviewed after care is
					 provided to validate that the services provided meet the definition of
					 emergency before payment is made. Once a decision to approve or deny the
					 requested services is made then the county OKDHS office is notified and the
					 county OKDHS office is responsible for notifying the applicant and the provider
					 of the decision.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-33 - Suspended claims review and/or prepayment review

Current through Vol. 41, No. 20, July 1, 2024
Suspended claims review and/or prepayment review occurs
					 after a healthcare good or service has been furnished and a claim for payment
					 has been filed with the Oklahoma Health Care Authority (OHCA) by the provider,
					 but before the claim has been paid. Suspended claims review and/or prepayment
					 review may be performed by the OHCA or its contractor or designee, and may take
					 the form of different types of reviews, including, but not limited to:
(1) Any claims review process(es) required by
				  federal and/or state law, including Section 447.45(f) of Title 42 of the Code
				  of Federal Regulations (C.F.R.);
(2) The suspended claims review process to
				  confirm, prior to payment, the medical necessity of the healthcare good or
				  service provided and use of the appropriate modifier, based on, among other
				  things, the claim's diagnosis, code, and/or modifier, as well as any attached
				  medical record(s) or other supporting documentation; and
(3) Any provider-specific prepayment review,
				  in which a provider's claims are temporarily held in the payment system,
				  pending review of medical records and/or other supporting documentation, in
				  order to confirm that the submitted claims were billed appropriately and relate
				  to healthcare goods or services that are covered and medically necessary. OHCA
				  shall notify the provider in writing within ten (10) business days before the
				  effective start date of any provider-specific prepayment review, informing the
				  provider as to the:
(A) Implementation date,
				  scope, and nature of the review;
(B) Process for submitting claims and
				  supporting documentation; and
(C)
				  Any accuracy goals that must be met before removal from the provider-specific
				  prepayment review status can occur.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-34 - Electronic visit verification (EVV) system

Current through Vol. 41, No. 20, July 1, 2024
An EVV system is a telephone-based, computer-based, or
					 other electronic-based system that verifies and documents the time and location
					 of services requiring an in-home visit, including, but not limited to,
					 self-directed services, in accordance with an approved prior authorization or
					 individual plan of care, and pursuant to Title 42 of the United States Code,
					 Section (§) 1396b(l).
(1)
Verification requirements.
An EVV system must verify the following
				  for in-home or community services:
(A) Type
				  of service performed (service code and any applicable modifier);
(B) Date of service;
(C) SoonerCare member identification number
				  of the individual receiving the service;
(D) Unique vendor identification number for
				  the individual providing the service (service provider);
(E) Location where service starts and ends;
				  and
(F) Time the service starts
				  and ends.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-35 - Oklahoma Statewide Health Information Exchange

Current through Vol. 41, No. 20, July 1, 2024
(a)
Authority.
This rule is promulgated under the authority granted in Title 63 of the Oklahoma Statutes  Section  1-133   (63 O.S. § 1-133). This Section is intended to be read in conjunction with applicable Oklahoma statutes and federal law.
(b)
Applicability and purpose.
(1)
Applicability.
This section shall apply to and govern the establishment and operation of the statewide health information exchange (HIE).
(2)
Purpose.
The Office of the State Coordinator for HIE is the office within the Oklahoma Health Care Authority (OHCA) that holds the power and duty to oversee the state-designated entity (SDE) for HIE.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-35 - Oklahoma State Health Information Network and Exchange (OKSHINE)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Authority.
This rule is promulgated under the authority granted in
				  Title 63 of the Oklahoma Statutes Section 1-133 (63 O.S. § 1-133). This
				  Section is intended to be read in conjunction with applicable Oklahoma statutes
				  and federal law.
(b)
Applicability and purpose.
(1)
Applicability.
This section shall apply to and govern the
				  establishment and operation of the statewide health information exchange (HIE),
				  herein referred to as OKSHINE.
(2)
Purpose.
OKSHINE is the state-designated organization that
				  facilitates the exchange of health information to and from authorized
				  individuals and health care organizations in the state for the purpose of
				  improving health outcomes, as per 63 O.S. § 1-133.
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 317:30-3-39 - Home and Community Based Services Waivers

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority operates or oversees the
					 operation of several Home and Community Based Services waivers. The waivers
					 allow individuals with physical or intellectual disabilities, requiring
					 institutional level of care, the opportunity to reside at home or in a
					 community based setting, while receiving institutional level of care services.
					 Brief summaries of the Waivers are set forth in OAC
					 317:30-3-40
					 and OAC
					 317:30-3-41.
					 Detailed information about each Waiver is available per the following
					 citations:
(1) Home and Community
				  Based Services Waivers for People with Intellectual Disabilities and Related
				  Conditions can be found at OAC
				  317:40-1-1
				  et seq.
(2) Home and Community
				  Based Services Waivers for People with Physical Disabilities:
(A) ADvantage Waiver information is available
				  per OAC
				  317:30-5-760 et
				  seq.
(B) Medically Fragile Waiver
				  information is available per OAC
				  317:50-1-1 et
				  seq.
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 317:30-3-40 - Home and community-based services (HCBS) waivers for persons with intellectual disabilities or certain persons with related conditions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Introduction to HCBS waivers for persons with intellectual
				  disabilities.
The Medicaid HCBS waiver programs are authorized per
				  Section 1915(c) of the Social Security Act.
(1) The Oklahoma Department of Human Services
				  (OKDHS) Developmental Disabilities Services Division (DDS) operates HCBS waiver
				  programs for persons with intellectual disabilities and certain persons with
				  related conditions. The Oklahoma Health Care Authority (OHCA), the State's
				  Medicaid agency, retains and exercises administrative authority over all HCBS
				  waiver programs.
(2) Each waiver
				  allows for the provision of specific SoonerCare-compensable services that
				  assist members to reside in the community and avoid
				  institutionalization.
(3) HCBS
				  waiver services:
(A) Complement and supplement
				  services available to members through the Medicaid State Plan or other federal,
				  state, or local public programs, as well as informal supports provided by
				  families and communities;
(B) Are
				  only provided to persons who are Medicaid eligible, outside of a nursing
				  facility, hospital, or institution;
(C) Are not intended to replace other
				  services and supports available to members; and
(D) Are authorized based solely on current
				  need.
(4) HCBS waiver
				  services must be:
(A) Appropriate to the
				  member's needs; and
(B) Included in
				  the member's individual plan (IP).
(i) The IP:
(I) Is developed annually by the member's
				  personal support team, per Oklahoma Administrative Code (OAC)
				  340:100-5-52;
				  and
(II) Contains detailed
				  descriptions of services provided, documentation of amount and frequency of
				  services, and types of providers to provide services.
(ii) Services are authorized, per OAC
				  340:100-3-33
				  and
				  340:100-3-33.1.
(5) DDS furnishes case management, targeted
				  case management, and services to members as Medicaid State Plan services, per
				  Section 1915(g)(1) of the Social Security Act and per OAC
				  317:30-5-1010
				  through
				  317:30-5-1012.
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 317:30-3-41 - Home and Community Based Services Waivers for persons with physical disabilities

Current through Vol. 41, No. 20, July 1, 2024
(a)
ADvantage Waiver
. The ADvantage Waiver Program is a Medicaid Home and Community Based Servces (HCBS) Waiver used to finance non-institutional long-term care services through Oklahoma's SoonerCare program for elderly and disabled individuals in specific waiver areas. To receive ADvantage Program services, individuals must meet the nursing facility level of care criteria, be age sixty-five (65) years or older, or age nineteen (19) or older if disabled. ADvantage Program members must be SoonerCare eligible and reside in the designated service area. The number of members in the ADvantage Waiver is limited.
(b)
Medically Fragile Waiver
. The Medically Fragile Waiver Program is a Medicaid Home and Community Based Services (HCBS) Waiver used to finance non-institutional long-term care services through Oklahoma's SoonerCare program for medically fragile individuals. To receive Medically Fragile Program services, individuals must be at least 19 years of age, be SoonerCare eligible, and meet the Oklahoma Health Care Authority (OHCA) skilled nursing facility (SNF) or hospital level of care (LOC) criteria. Eligibility does not guarantee placement in the program as Waiver membership is limited.
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 317:30-3-41 - Home and Community Based Services Waivers for persons with physical disabilities

Current through Vol. 41, No. 20, July 1, 2024
(a)
ADvantage Waiver.
The ADvantage Waiver Program is a Medicaid Home
				  and Community Based Services (HCBS) Waiver used to finance non-institutional
				  long-term care services through Oklahoma's SoonerCare program for elderly and
				  disabled individuals in specific waiver areas. To receive ADvantage Program
				  services, individuals must meet the nursing facility level of care criteria, be
				  age 65 years or older, or age 21 or older if disabled. ADvantage Program
				  members must be SoonerCare eligible and reside in the designated service area.
				  The number of members in the ADvantage Waiver is limited.
(b)
Medically Fragile Waiver.
The Medically Fragile Waiver Program is a Medicaid Home and Community Based
				  Services (HCBS) Waiver used to finance non-institutional long-term care
				  services through Oklahoma's SoonerCare program for medically fragile
				  individuals. To receive Medically Fragile Program services, individuals must be
				  at least 19 years of age, be SoonerCare eligible, and meet the OHCA skilled
				  nursing facility (SNF) or hospital level of care (LOC) criteria. Eligibility
				  does not guarantee placement in the program as Waiver membership is
				  limited.
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 28 Ok Reg 1401, 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-42 - Services in a Nursing Facility (NF)

Current through Vol. 41, No. 20, July 1, 2024
Nursing facility services are those services furnished
					 pursuant to a physician's orders which require the skills of technical or
					 professional personnel, e.g., registered nurses, licensed practical nurses,
					 physical therapists, occupational therapists, speech pathologists or
					 audiologists. This care is provided by nursing facilities licensed under State
					 law to provide, on a regular basis, health related care and services to
					 individuals who do not require hospitalization but whose physical or mental
					 condition requires care and services above the level of room and board which
					 can be made available to them only through a nursing facility.
(1) To be eligible for nursing facility
				  services the individual must:
(A) Require a
				  treatment plan involving the planning and administration of services which
				  require skills of licensed technical or professional personnel that are
				  provided directly or under the supervision of such personnel and are prescribed
				  by the physician;
(B) Have a
				  physical impairment or combination of physical and mental
				  impairments;
(C) Require
				  professional nursing supervision (medication, hygiene and dietary
				  assistance);
(D) Lack the ability
				  to care for self or communicate needs to others; and
(E) Require medical care and treatment in a
				  nursing facility to minimize physical health regression and deterioration. A
				  physician's order and results from a standardized assessment which evaluates
				  type and degree of disability and need for treatment must support the
				  individual's need for NF level of care. Only standardized assessments approved
				  by the OHCA and administered in accordance with Medicaid approved procedures
				  shall be used to make the NF level of care determination.
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 317:30-3-43 - Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities(ICF/IID)

Current through Vol. 41, No. 20, July 1, 2024
Services in an ICF/IID facility are provided to individuals
					 per OAC
					 317:30-5-122 and
					 OAC
					 317:35-9-45.
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 28 Ok Reg 1409, 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-44 - Personal care

Current through Vol. 41, No. 20, July 1, 2024
Personal care is a service provided in a member's home. To
					 receive the service, the member must have met the appropriate level of care in
					 accordance with procedures found in OAC 317:35-9. In geographic areas
					 designated as ADvantage Program phase in areas, personal care services may be
					 provided by agency providers who contract with the Medicaid agency for the
					 provision of services. The service may be provided by individual personal care
					 providers in geographic areas where there is insufficient agency providers to
					 adequately serve the population.
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 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-45 - Services for persons age 65 or older in mental health hospitals

Current through Vol. 41, No. 20, July 1, 2024
Services for persons age 65 years or older in mental health
					 hospitals are mental health services provided in an inpatient hospital setting
					 to eligible categorically needy individuals whose condition cannot adequately
					 be treated on an outpatient basis.
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 3 - General Provider Policies › Part 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-46 - Services for persons infected with tuberculosis

Current through Vol. 41, No. 20, July 1, 2024
(a) Oklahoma Medicaid provides optional
				  coverage of tuberculosis (TB) related services for certain TB infected
				  individuals. Services covered under this program are not restricted to the
				  Medicaid scope of coverage or limitations. Services for TB infected individuals
				  that exceed the scope of Medicaid services must be prior authorized.
				  Individuals eligible only under the optional TB-related services program can
				  receive TB related services such as:
(1)
				  Prescribed medications:
(A) Prescription
				  drugs indicated for the treatment of TB up to the Medicaid established
				  prescription limit; and
(B) Other
				  drugs related to the treatment of TB beyond the prescriptions covered under
				  Medicaid, require prior authorization obtained from the University of Oklahoma
				  College of Pharmacy using form "Petition for TB Related Therapy".
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 317:30-3-46.1 - Poison control services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 3636, eff 6-21-95 (emergency); Added at 13 Ok Reg 1645, eff 5-27-96; Revoked at
					 15 Ok Reg 3815, eff 7-1-98 (emergency); Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-47 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program [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 13 Ok Reg 1519, eff 3-27-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Amended at 17 Ok Reg 2368, eff 6-26-00; Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-48 - Periodicity schedule [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 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-49 - Initial screening examination [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 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-50 - Screening components [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 48, eff 9-11-98 (emergency); Amended at 16 Ok Reg
					 1429, eff 5-27-99; Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-51 - Diagnosis and treatment [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 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-52 - Vision 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; Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-53 - 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 21 Ok Reg 2201, eff 6-25-04; Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-54 - Hearing 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 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; Revoked 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-55 - Periodic and interperiodic screening examinations [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 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-56 - Partial screening examination [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 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 3 - GENERAL MEDICAL PROGRAM INFORMATION › Section 317:30-3-57 - General SoonerCare coverage - categorically needy

Current through Vol. 41, No. 20, July 1, 2024
The following are general SoonerCare coverage guidelines
					 for the categorically needy:
(1)
				  Inpatient hospital services.
(A) Adult
				  coverage for inpatient hospital stays as described at Oklahoma Administrative
				  Code (OAC)
				  317:30-5-41.
(B) Coverage for members under twenty-one
				  (21) years of age is not limited. All admissions must be medically necessary.
				  All psychiatric admissions require prior authorization for an approved length
				  of stay.
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 317:30-3-57.1 - Coverage of routine services in relation to clinical trials

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage.
The Oklahoma Health Care Authority (OHCA) will cover
				  routine patient costs provided under a qualifying clinical trial to an eligible
				  member. The OHCA does not:
(1) Determine
				  eligibility for participation in any research study; or
(2) Reimburse for any costs associated in the
				  research study, other than for routine patient costs for clinical studies, as
				  defined in this Section and in the Oklahoma Medicaid State
				  Plan.
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 317:30-3-58 - General Medicaid coverages - medically needy [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