reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-60 - Subacute level of care

Current through Vol. 41, No. 20, July 1, 2024
Subacute (SA) level of care is skilled care provided by a
					 long term care hospital to patients with medically complex needs. The patients
					 who are treated include those with complex pulmonary problems, children
					 requiring long-term care to improve or maintain their physical condition or
					 prevent deterioration to children who are terminally ill, children who are
					 experiencing severe developmental disabilities and
					 multi-handicaps.
Added at 15 Ok Reg
					 1100, eff 1-6-98 (emergency); Added at 15 Ok Reg 1535, eff
					 5-11-98
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-61 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
To be eligible for reimbursement hospitals must be Medicare
					 certified and have a current contract on file with the Oklahoma Health Care
					 Authority. The facility must also be designated as a long term care facility by
					 the Social Security Administration and be appropriately licensed as a
					 Children's Specialty Hospital. Payment will be made to licensed Children's
					 hospitals specializing in subacute nursing and rehabilitative
					 services.
Added at 15 Ok Reg
					 1100, eff 1-6-98 (emergency); Added at 15 Ok Reg 1535, eff
					 5-11-98
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-62 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
There is no coverage for adults.
(b)
Children.
Payment is made to
				  long term care hospitals for subacute medical and rehabilitative services for
				  persons under the age of 21 within the scope of the Authority's Medical
				  Programs, provided the services are reasonable for the diagnosis and treatment
				  of illness or injury, or to improve the functioning of a malformed body member.
(1)
Inpatient services.
(A) All inpatient services are subject to
				  post-payment utilization review by the Oklahoma Health Care Authority, or its
				  designated agent. These reviews will be based on OHCA's, or its designated
				  agent's, admission criteria on severity of illness and intensity of treatment.
(i) It is the policy and intent of the
				  Oklahoma Health Care Authority to allow hospitals and physicians the
				  opportunity to present any and all documentation available to support the
				  medical necessity of an admission and/or extended stay of a Medicaid recipient.
				  If the OHCA, or its designated agent, upon their initial review determines the
				  admission should be denied, a notice is sent to the facility and the attending
				  physician(s) advising them of the decision. This notice also advises that a
				  reconsideration request may be submitted within 60 days. Additional information
				  submitted with the reconsideration request will be reviewed by the OHCA, or its
				  designated agent, who utilizes an independent physician advisor. If the denial
				  decision is upheld through this review of additional information, OHCA is
				  informed. At that point, OHCA sends a letter to the hospital and physician
				  requesting refund of the Title XIX payment previously made on the denied
				  admission.
(ii) If the hospital or
				  attending physician did not request reconsideration by the OHCA, or its
				  designated agent, the OHCA, or its designated agent, informs OHCA that there
				  has been no request for reconsideration and as a result their initial denial
				  decision is final. OHCA, in turn, sends a letter to the hospital and physician
				  requesting refund of the amount of Title XIX payment previously made on the
				  denied admission.
(iii) If an OHCA,
				  or its designated agent, review results in denial and the denial is upheld
				  throughout the review process and refund from the hospital and physician is
				  required, the Medicaid recipient cannot be billed for the denied services. The
				  reconsideration process outlined in (A) of this paragraph will end on July 1,
				  2006.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-65 - Ancillary services

Current through Vol. 41, No. 20, July 1, 2024
Ancillary services are those items which are not considered
					 routine services. Ancillary services may be billed separately to the SoonerCare
					 program, unless reimbursement is available from Medicare or other insurance or
					 benefit programs. Coverage criteria, utilization controls and program
					 limitations are specified in Part 17 of OAC 317:30-5. Ancillary services are
					 limited to the following services:
(1)
				  Services requiring prior authorization:
(A)
				  Ventilators and supplies.
(B) Total
				  Parenteral Nutrition (TPN), and supplies.
(C) Custom seating for wheelchairs.
(D) Enteral feeding.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-66 - Reimbursement for inpatient hospital subacute services

Current through Vol. 41, No. 20, July 1, 2024
Reimbursement for inpatient hospital subacute services is
					 made based on cost reports submitted to the OHCA. The cost reports will be
					 reviewed annually to ensure that the interim rate is appropriate for the
					 current cost/case mix of care for these facilities and to make settlement to
					 the facility based on total allowable costs under Mecicare/Medicaid cost
					 principles.
Added at 15 Ok Reg 1100, eff 1-6-98 (emergency) ; Added
						at 15 Ok Reg 1535, eff 5-11-98 ; Amended at 30 Ok Reg 1170, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-67 - Cost reports

Current through Vol. 41, No. 20, July 1, 2024
Each long term care facility is required to submit, on
					 uniform cost reports designed by the Authority, an annual cost report for the
					 fiscal year just completed. The fiscal year is July 1 through June 30. The
					 reports must be submitted to the Authority on or before the first day of
					 September.
(1) When there is a change
				  of operation or ownership, the selling or closing ownership is required to file
				  a cost report for that portion of the fiscal year it was in operation. The
				  successor ownership is correspondingly required to file a cost report for that
				  portion of the fiscal year it was in operation.
(2) Cost report forms and instructions are
				  mailed annually to each facility before the first of July. The completed forms
				  are to be returned to the Authority, Attention: Reimbursement and
				  Audit.
(3) Normally, all ordinary
				  and necessary expenses incurred in the conduct of an economical and efficiently
				  operated business are recognized as allowable.
(4) All reports are subject to on-site audits
				  and are deemed public records.
(A) Only
				  "allowable costs" may be included in the cost reports, (costs should be net of
				  any offsets of credits). Allowable costs include all items of Medicaid-covered
				  expense which pediatric long term care hospitals incur in the provision of
				  routine services. "Routine services" include, but are not limited to:
(i) regular room,
(ii) dietary and nursing services,
(iii) minor medical and surgical
				  supplies,
(iv) over-the-counter
				  medications,
(v) transportation,
				  and
(vi) the use and maintenance of
				  equipment and facilities essential to the provision of routine care.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 4 - LONG TERM CARE HOSPITALS › Section 317:30-5-68 - Rate Appeals [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg
					 1100, eff 1-6-98 (emergency); Added at 15 Ok Reg 1535, eff 5-11-98; Revoked at
					 15 Ok Reg 3784, eff 7-1-98 (emergency); Revoked at 16 Ok Reg 1424, eff
					 5-27-99
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-70 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Eligible providers are entities licensed under applicable
					 provisions of Oklahoma law as pharmacies, including non-resident pharmacies not
					 located in Oklahoma that are transacting or doing business in Oklahoma by
					 soliciting, receiving, dispensing, and/or delivering prescription medications
					 and devices to Oklahoma residents.
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 17 Ok Reg 2383, eff 6-26-00; Amended at 25 Ok Reg 2662, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-70.1 - Pharmacist responsibility

Current through Vol. 41, No. 20, July 1, 2024
Eligible providers in the SoonerCare program are expected
					 to act in accordance with the rules of professional conduct as promulgated by
					 the Oklahoma Board of Pharmacy, 59 Oklahoma Statutes, Sec. 353.7(12). A
					 pharmacist may refuse to dispense any prescription which appears to be
					 improperly executed or which, in their professional judgment, is unsafe as
					 presented.
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 25 Ok Reg 2662, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-70.2 - Record retention/post payment review

Current through Vol. 41, No. 20, July 1, 2024
Post-payment audits of the SoonerCare program are performed
					 routinely by state and federal agencies. This Section applies to any
					 post-payment audit regardless of the agency performing the audit. Pharmacies
					 may be selected at random, as a result of a peer comparison, or data analysis
					 for audits. The pharmacy is required to provide original written prescriptions
					 and signature logs as well as purchase invoices and other records necessary to
					 document their compliance with program guidelines at the time of the audit.
					 Written prescriptions must conform with the standards set forth in 42 United
					 States Code, Sec. 1396b(i) and related federal regulations requiring the use of
					 a tamper-resistant prescription pad. These standards do not apply to
					 prescriptions transmitted via telephone, facsimile or electronic prescription
					 systems. Original written prescriptions are defined as any order for drug or
					 medical supplies written or signed, or transmitted by word of mouth, telephone
					 or other means of communication by a practitioner licensed by law to prescribe
					 such drugs and medical supplies intended to be filled, compounded, or dispensed
					 by a pharmacist. Signature logs are defined as any document which verifies that
					 the prescription was delivered to the member or their representative. This may
					 include electronic forms of tracking including but not limited to scanning a
					 bar code of the filled prescription. The electronic tracking system must be
					 able to produce a copy of the scan for audit purposes. Records must be
					 available for seven (7) years. Failure to provide the requested information to
					 the Reviewer may result in a recommendation ranging from a potential recoupment
					 of SoonerCare payments for the service to contract
					 termination.
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 19 Ok Reg 2773, eff 4-24-02 (emergency); Amended
					 at 20 Ok Reg 1193, eff 5-27-03; Amended at 24 Ok Reg 902, eff 5-11-07; Amended
					 at 25 Ok Reg 118, eff 8-1-07 (emergency); Amended at 25 Ok Reg 1192, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-70.3 - Prescriber identification numbers

Current through Vol. 41, No. 20, July 1, 2024
(a) Pharmacies must use the prescriber's
				  National Provider Identification (NPI) number to identify the prescribing
				  provider.
(b) To comply with
				  Federal law, claims for covered over-the-counter products must be prescribed by
				  a health care professional with prescriptive authority. The claim should be
				  submitted using the prescriber name and NPI number .
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 19 Ok Reg 2773, eff 4-24-02 (emergency); Amended
					 at 20 Ok Reg 1193, eff 5-27-03; Amended at 25 Ok Reg 2662, eff
					 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-70.4

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-71 - Drug Utilization Review [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 17 Ok Reg 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-72 - Categories of service eligibility

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage for adults.
Prescription drugs for categorically needy adults are covered as set forth in this subsection.
(1) With the exception of (2) and (3) of this subsection, categorically needy adults are eligible for a maximum of six (6) covered prescriptions per month with a limit of two (2) brand name prescriptions. A prior authorization may be granted for a third brand name if determined to be medically necessary by OHCA and if the member has not already utilized their six (6) covered prescriptions for the month.
(2) Subject to the limitations set forth in Oklahoma Administrative Code (OAC) 317:30-5-72.1, 317:30-5-77.2, and 317:30-5-77.3, exceptions to the six (6) medically necessary prescriptions per month limit are:
(A) Unlimited monthly medically necessary prescriptions for categorically related individuals who are residents of nursing facilities (NF) or intermediate care facilities for individuals with an intellectual disability (ICF/IID); and
(B) Seven (7) additional medically necessary prescriptions which are generic products per month to the six (6) covered under the State Plan [including three (3) brand name prescriptions] are allowed for adults receiving services under the 1915(c) Home and Community-Based Services (HCBS) waivers. Medically necessary prescriptions beyond the three (3) brand name or thirteen (13) total prescriptions will be covered with prior authorization.
(3) For purposes of this Section, "exempt from the prescription limit" means claims filed for certain prescriptions will not count toward the prescriptions allowed per month. A complete list of the selected drugs exempt from monthly limits can be viewed on the agency's website at
www.okhca.org/rx
(4) When a brand drug is preferred over its generic equivalent due to lower net cost, that drug shall not count toward the brand limit; however, it will count toward the monthly prescription limit.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-72 - Categories of service eligibility

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage for adults.
Prescription drugs for categorically needy adults are covered as set forth in
				  this subsection.
(1) With the exception of
				  (2) and (3) of this subsection, categorically needy adults are eligible for a
				  maximum of six (6) covered prescriptions per month with a limit of two (2)
				  brand name prescriptions. A prior authorization may be granted for a third
				  brand name if determined to be medically necessary by OHCA and if the member
				  has not already utilized their six (6) covered prescriptions for the month.
(2) Subject to the limitations set
				  forth in Oklahoma Administrative Code (OAC)
				  317:30-5-72.1,
				  317:30-5-77.2,
				  and
				  317:30-5-77.3,
				  exceptions to the six (6) medically necessary prescriptions per month limit
				  are:
(A) Unlimited monthly medically
				  necessary prescriptions for categorically related individuals who are residents
				  of nursing facilities(NF) or intermediate care facilities for individuals with
				  an intellectual disability (ICF/IID) ; and
(B) Seven (7) additional medically necessary
				  prescriptions which are generic products per month to the six (6) covered under
				  the State Plan [including three (3) brand name prescriptions] are allowed for
				  adults receiving services under the 1915(c) Home and Community-Based Services
				  (HCBS) waivers . Medically necessary prescriptions beyond the three (3) brand
				  name or thirteen (13) total prescriptions will be covered with prior
				  authorization.
(3) For
				  purposes of this Section, "exempt from the prescription limit" means claims
				  filed for any of these prescriptions will not count toward the prescriptions
				  allowed per month. Drugs exempt from the prescription limit include:
(A) Antineoplastics;
(B) Anti-retroviral agents for persons
				  diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or who have tested
				  positive for the Human Immunodeficiency Virus (HIV);
(C) Frequently monitored prescription drugs.
				  A complete list of the selected drugs considered as frequently monitored can be
				  viewed on the agency's website at
www.okhca.org
.
(D) Medication-assisted treatment (MAT) drugs
				  for opioid use disorder;
(E)
				  Contraceptives;
(F) Hemophilia
				  drugs;
(G) Compensable smoking and
				  tobacco cessation products;
(H)
				  Naloxone for use in opioid overdose;
(I) Certain carrier or diluent solutions used
				  in compounds (i.e. sodium chloride, sterile water, etc.);
(J) Drugs used for the treatment of
				  tuberculosis; and
(K) Prenatal
				  vitamins.
(4) When a
				  brand drug is preferred over its generic equivalent due to lower net cost, that
				  drug shall not count toward the brand limit; however, it will count toward the
				  monthly prescription limit.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-72.1 - Drug benefit

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) administers and
					 maintains an Open Formulary subject to the provisions of
					 42 U.S.C. §
											1396r-8. The OHCA covers a drug that has been
					 approved by the Food and Drug Administration (FDA) and whose manufacturers have
					 entered into a drug rebate agreement with the Centers for Medicare and Medicaid
					 Services (CMS), subject to the following exclusions and limitations.
(1) The following drugs, classes of drugs, or
				  their medical uses are excluded from coverage:
(A) Agents used to promote fertility.
(B) Agents primarily used to
				  promote hair growth.
(C) Agents
				  used for cosmetic purposes.
(D)
				  Agents used primarily for the treatment of anorexia or weight gain. Drugs used
				  primarily for the treatment of obesity, such as appetite suppressants are not
				  covered. Drugs used primarily to increase weight are not covered unless
				  otherwise specified.
(E) Agents
				  that are investigational, experimental or whose side effects make usage
				  controversial including agents that have been approved by the FDA but are being
				  investigated for additional indications. For more information regarding
				  experimental or investigational including clinical trials see, OAC
				  317:30-3-57.1.
(F) Covered
				  outpatient drugs which the manufacturer seeks to require as a condition of sale
				  that associated tests or monitoring services be purchased exclusively from the
				  manufacturer or designee.
(G)
				  Agents when used for the treatment of sexual or erectile dysfunction, unless
				  such agents are used to treat a condition, other than sexual or erectile
				  dysfunction, for which the agents have been approved by the FDA.
(H) Agents used for the symptomatic relief of
				  cough and colds.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-73 - Coverage for children (categorically and 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 761, eff 12-24-96 (emergency); Amended at 14 Ok
					 Reg 1785, eff 5-27-97; Amended at 15 Ok Reg 1114, eff 1-6-98 (emergency);
					 Amended at 15 Ok Reg 1535, eff 5-11-98; Revoked at 17 Ok Reg 2383, eff
					 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-74 - Vocational rehabilitation [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 16 Ok Reg 685, eff 12-28-98 (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 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-75 - Individuals eligible for Part B of Medicare [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Revoked at 17 Ok Reg
					 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-76 - Generic drugs

Current through Vol. 41, No. 20, July 1, 2024
All eligible providers are required to substitute generic
					 medications for prescription name brand medications with the exception of
					 prescriptions in which a brand necessary certification as provided in OAC
					 317:30-5-77
					 is made by a prescribing provider or when the agency has notified pharmacy
					 providers that the net cost of the brand name medication is lower than the net
					 cost of the generic medication.
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 3446, eff 7-1-99
					 (emergency)1; Amended at 17 Ok Reg 2383, eff
					 6-26-00
1On October 15, 1999, the
					 District Court of Oklahoma County issued a Temporary Injunction Order
					 "prohibiting, barring, enjoining and restraining the Oklahoma Health Care
					 Authority from relying upon, maintaining, employing or using t[his] emergency
					 rule." [See Astrazeneca LP v. Oklahoma Health Care Authority, Case No.
					 CJ-99-5898, 10-15-99, Judge Bryan C. Dixon, District Court of Oklahoma County]
					 On 6-26-00, the emergency action was superseded by a permanent action, and on
					 10-10-00, the case was dismissed with
					 prejudice.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-77 - Brand necessary certification

Current through Vol. 41, No. 20, July 1, 2024
(a) When a product is available in both a
				  brand and generic form, a prior authorization is required before the branded
				  product may be dispensed. The prescribing provider must certify the brand name
				  drug product is medically necessary for the well being of the patient,
				  otherwise a generic must be substituted for the name brand product.
(1) The certification must be written in the
				  physician's or other prescribing provider's handwriting.
(2) Certification must be written directly on
				  the prescription blank or on a separate sheet which is attached to the original
				  prescription.
(3) A standard phrase
				  indicating the need for a specific brand is required. The OHCA recommends use
				  of the phrase "Brand Necessary".
(4) It is unacceptable to use a printed box
				  on the prescription blank that could be checked by the physician to indicate
				  brand necessary, or to use a hand-written statement that is transferred to a
				  rubber stamp and then stamped onto the prescription blank.
(5) If a physician phones a prescription to
				  the pharmacy and indicates the need for a specific brand, the physician should
				  be informed of the need for a handwritten certification. The pharmacy can
				  either request that the certification document be given to the patient who then
				  delivers it to the pharmacy upon receipt of the prescription, or request the
				  physician send the certification through the mail.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-77.1 - Dispensing quantity

Current through Vol. 41, No. 20, July 1, 2024
(a) Prescription
				  quantities shall be limited to a thirty-four (34) day supply, except in the
				  following situations:
(1) The Drug
				  Utilization Review (DUR) Board has recommended a different day supply or
				  quantity limit based on published medical data, including the manufacturer's
				  package insert;
(2) The product is
				  included on the Maintenance List of medications, which are exempted from this
				  limit, and may be dispensed up to a ninety (90) day supply ;
(3) The manufacturer of the drug recommends a
				  dispensing quantity less than a thirty-four (34) day supply.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-77.3 - Product-based prior authorization (PBPA)

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) utilizes a PBPA
					 system pursuant to its authority under Section 1396r-8 of Title 42 of the
					 United States Code and Section
					 5030.3(A)
					 of Title 63 of the Oklahoma Statutes. The PBPA program, which includes step
					 therapy protocols as defined in 63 O.S. § 7310(A)(4), is not a drug
					 formulary, which is separately authorized in
					 42 U.S.C. §
											1396r-8. In the PBPA system, drugs are placed
					 into two (2) or more tiers based on similarities in clinical efficacy,
					 side-effect profile, and cost-effectiveness, after recommendation by the Drug
					 Utilization Review (DUR) Board and approval by the OHCA Board. Drugs placed in
					 tier one (1) generally require no prior authorization; however, drugs placed in
					 any tier may be subject to prior authorization.
(1) Exceptions to the requirement of prior
				  authorization shall be granted based upon a properly-supported justification
				  submitted by the prescribing provider demonstrating one (1) or more of the
				  bases for exception identified in Oklahoma Administrative Code (OAC)
				  317:30-5-77.4(b)(3).
(2) The
				  manufacturer or labeler of a product may opt to participate in the state
				  supplemental drug rebate program to move a product from a higher tier to a
				  lower tier which will remove or reduce the prior authorization requirement for
				  that product. Supplemental rebate negotiations are done through Sovereign
				  States Drug Consortium (SSDC); a multi-state purchasing pool.
(A) Supplemental rebate agreements shall be
				  in effect for one (1) year and may be terminated at the option of either party
				  with a sixty (60) day notice. Supplemental rebate agreements are subject to the
				  approval of the Centers for Medicare and Medicaid Services (CMS). Termination
				  of a supplemental rebate agreement will result in the specific product
				  reverting to the previously assigned higher tier in the PBPA program.
(B) Drugs or drug categories which
				  are not part of the PBPA program as outlined in 63 O.S. § 5030.5 may be
				  eligible for supplemental rebate participation. The OHCA DUR Board may
				  recommend supplemental rebate eligibility for drugs or drug categories after
				  considering clinical efficacy, side effect profile, cost-effectiveness, and
				  other applicable criteria.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-77.4 - Step therapy exception process

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
(1)
"Exigent circumstances"
means circumstances in which a delay in receiving a prescription drug will
				  jeopardize the member's life or health or ability to attain, maintain, or
				  regain maximum function.
(2)
"Step therapy"
or
"step therapy protocol"
means a
				  protocol or program that establishes a specific sequence in which prescription
				  drugs for a specified medical condition that are medically appropriate for a
				  particular patient are covered by Medicaid. Step therapy protocols are based
				  upon the recommendation of the Drug Utilization Review (DUR) Board, as approved
				  by the Oklahoma Health Care Authority (OHCA) Board.
(3) A
"step therapy exception"
means the process by which a step therapy protocol is overridden in favor of
				  immediate coverage of a SoonerCare provider's selected prescription drug.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-78.2 - Falsification of claims

Current through Vol. 41, No. 20, July 1, 2024
No pharmacist shall knowingly present or cause to be
					 presented a false or fraudulent claim for payment. No pharmacist shall
					 knowingly make, use or caused to be made or used, a false record or statement
					 to get a false or fraudulent claim paid or approved. The term knowingly shall
					 mean that a person, with respect to information has actual knowledge of the
					 information, acts in deliberate ignorance of the truth or falsity of the
					 information or acts in reckless disregard of the truth or falsity of the
					 information. Violation of this section may lead to actions from education of
					 the provider, to recoupment of payment to criminal penalties as prescribed in
					 OAC
					 317:30-3-18.
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 25 Ok Reg
					 2662, eff 7-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-79 - Quantity dispensed [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 761, eff 12-24-96 (emergency); Amended at 14 Ok
					 Reg 1785, eff 5-27-97; Revoked at 16 Ok Reg 3446, eff 7-1-99
					 (emergency)1; Revoked at 17 Ok Reg 2383, eff
					 6-26-00
1On October 15, 1999, the
					 District Court of Oklahoma County issued a Temporary Injunction Order
					 "prohibiting, barring, enjoining and restraining the Oklahoma Health Care
					 Authority from relying upon, maintaining, employing or using t[his] emergency
					 rule." [See Astrazeneca LP v. Oklahoma Health Care Authority, Case No.
					 CJ-99-5898, 10-15-99, Judge Bryan C. Dixon, District Court of Oklahoma County]
					 On 6-26-00, the emergency action was superseded by a permanent action, and on
					 10-10-00, the case was dismissed with
					 prejudice.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-80

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 19 Ok Reg 2773, eff 4-24-02 (emergency); Amended at 20 Ok
					 Reg 1193, eff 5-27-03
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-81 - 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 1429, eff 5-27-99; Revoked at 17 Ok Reg 2383, eff
					 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-82 - Prescriber numbers [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 17 Ok Reg 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-83 - Pharmacist's responsibility [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 17 Ok Reg 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-84 - Record retention [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 17 Ok Reg 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-85 - Special billing procedures [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 17 Ok Reg 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-86 - Drug Utilization Review (DUR) program

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority (OHCA)
				  Drug Utilization Review (DUR) program is authorized by regulations contained in
				  the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) to conduct prospective
				  and retrospective review of pharmacy claims to ensure that prescriptions are:
(1) Appropriate;
(2) Medically necessary; and
(3) Not likely to result in adverse medical
				  results.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-86.1 - Disease state management [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 2383, eff 6-26-00; Amended at 21 Ok Reg 2485, eff 7-11-05; Revoked at 24 Ok Reg
					 2877, eff 7-1-07 (emergency); Revoked at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-86.2

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 2383, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-87 - 340B Drug Discount Program

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The 340B Drug Discount Program is a drug-pricing program established under
				  section 256b of Title 42 of the United States Code (U.S.C) under which a
				  manufacturer of covered outpatient drugs agrees that it will not charge a 340B
				  covered entity more than the 340B price for a 340B covered outpatient
				  drug.
(b) Covered entities
				  participating in the 340B Drug Discount Program will adhere to the following
				  provisions outlined in this Section and as defined in
				  42
				  U.S.C. §
											256b. Covered entities must:
(1) Notify the OHCA Pharmacy Department in
				  writing within thirty (30) days of any changes in 340B Program participation,
				  as well as any changes in name, address, National Provider Identification
				  (NPI), SoonerCare Provider Number, etc.
(2) Maintain their status on the Health
				  Resources & Services Administration (HRSA) Medicaid Exclusion File (MEF)
				  and report any changes to the OHCA within thirty (30) days.
(3) Execute a contract addendum with the OHCA
				  in addition to their provider contract.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95 - General provisions and eligible providers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Eligible
				  settings for inpatient psychiatric services.
The following individuals
				  may receive SoonerCare-reimbursable inpatient psychiatric services in the
				  following eligible settings:
(1) Individuals
				  under twenty-one (21) years of age, in accordance with OAC
				  317:30-5-95.23, may receive
				  SoonerCare-reimbursable inpatient psychiatric services in a psychiatric unit of
				  a general hospital, a psychiatric hospital, or a PRTF; and may receive chemical
				  dependency detoxification/withdrawal management services in a psychiatric unit
				  of a general hospital or in a psychiatric hospital.
(2) Individuals ages twenty-one (21) and
				  older may receive SoonerCare-reimbursable inpatient psychiatric and/or chemical
				  dependency detoxification/withdrawal management services in a psychiatric unit
				  of a general hospital or in a psychiatric hospital.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.2 - Coverage for children [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
					 19 Ok Reg 2138, eff 6-27-02; Amended at 23 Ok Reg 771, eff 3-9-06 (emergency);
					 Revoked at 23 Ok Reg 2508, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.3 - Medicare eligible individuals [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg
					 3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
					 19 Ok Reg 2938, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03;
					 Amended at 21 Ok Reg 2485, eff 7-11-05; Revoked at 23 Ok Reg 2508, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.4 - Individual plan of care for adults aged twenty-one (21) to sixty-four (64)

Current through Vol. 41, No. 20, July 1, 2024
(a) Before or
				  immediately after admission to a psychiatric unit of a general hospital or
				  psychiatric hospital, the attending physician or staff physician must establish
				  a written plan of care for each member aged twenty-one (21) to sixty-four (64).
				  The plan of care must include:
(1) Diagnoses,
				  symptoms, complaints, and complications indicating the need for
				  admission;
(2) A description of the
				  functional level of the individual;
(3) Objectives;
(4) Any order for medication, treatments,
				  restorative and rehabilitative services, activities, therapies, social
				  services, diet, and special procedures recommended for the health and safety of
				  the member;
(5) Plans for
				  continuing care, including review and modification to the plan of care;
				  and
(6) Plans for
				  discharge.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.5 - Physician review of prescribed medications for adults age 21 to 64

Current through Vol. 41, No. 20, July 1, 2024
All prescribed medications for adults age 21 to 64 must be
					 reviewed by the physician at least every seven days; the review must be
					 documented in the member's medical record by the physician signing his/her name
					 and title and dating the orders.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended
					 at 28 Ok Reg 1452, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.6 - Medical, psychiatric, and social evaluations for adults aged twenty-one (21) to sixty-four (64)

Current through Vol. 41, No. 20, July 1, 2024
The record for an adult member aged twenty-one (21) to
					 sixty-four (64) must contain complete medical, psychiatric, and social
					 evaluations.
(1) The evaluations must
				  be completed as follows:
(A) History and
				  physical must be completed within twenty-four (24) hours of admission by a
				  licensed independent practitioner [Allopathic Doctor, Osteopathic Doctor,
				  Advanced Practice Registered Nurse (APRN), or Physician Assistant
				  (PA)].
(B) Psychiatric evaluation
				  must be completed within sixty (60) hours of admission by an Allopathic or
				  Osteopathic Physician with a current license and a board certification/eligible
				  in psychiatry, an APRN with a psychiatric certification or a PA.
(C) Psychosocial evaluation must be completed
				  within seventy-two (72) hours of admission by a licensed independent
				  practitioner (Allopathic Doctor, Osteopathic Doctor, APRN, or PA), an LBHP, or
				  a licensure candidate as defined in OAC
				  317:30-5-240.3.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.7 - Active treatment for adults age 21 to 64

Current through Vol. 41, No. 20, July 1, 2024
Active treatment must be provided to each adult member age
					 21 to 64. The active treatment program must be appropriate to the needs of the
					 member and be directed toward restoring and maintaining optimal levels of
					 physical and psychiatric-social functioning. The services and individual plan
					 of care must be recovery focused, trauma informed, and specific to culture, age
					 and gender.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 24 Ok Reg 2880, eff 7-1-07 (emergency); Amended
					 at 25 Ok Reg 1161, eff 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.8 - Nursing services for adults age 21 to 64

Current through Vol. 41, No. 20, July 1, 2024
Each facility providing nursing services to adults age 21
					 to 64 must have a qualified Director of Psychiatric Nursing. In addition to the
					 Director of Nursing, there must be adequate numbers of registered nurses,
					 licensed practical nurses, and mental health workers to provide nursing care
					 necessary under the active treatment program and to maintain progress notes on
					 each member. A registered nurse must document member progress at least weekly.
					 The progress notes must contain recommendations for revisions in the treatment
					 plan, as needed, as well as an assessment of the member's progress as it
					 relates to the treatment plan goals and objectives.
Added at 23 Ok Reg
					 2508, eff 6-25-06; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended
					 at 28 Ok Reg 1452, eff 6-25-11