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 3 - HOSPITALS › Section 317:30-5-41.2 - Organ transplants

Current through Vol. 41, No. 20, July 1, 2024
Solid organ and bone marrow/stem cell transplants are
					 covered when appropriate and medically necessary.
(1) Transplant procedures, except kidney and
				  cornea, must be prior authorized to be compensable.
(2) To be prior authorized all procedures are
				  reviewed based on appropriate medical criteria.
(3) To be compensable under the SoonerCare
				  program all transplants must be performed at a facility which meets the
				  requirements contained in Section 1138 of the Social Security Act.
(4) Procedures considered experimental or
				  investigational are not covered. For more information regarding experimental or
				  investigational including clinical trials, see OAC 317:30-3-57.1.
(5) Donor search and procurement services are
				  covered for transplants consistent with the methods used by the Medicare
				  program for organ acquisition costs.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 2060, eff
					 6-25-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42 - Coverage for children [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 3607, eff 6-18-96 (emergency); Amended at 13 Ok
					 Reg 3585, eff 7-16-96 (emergency); Amended at 14 Ok Reg 1215, eff 8-7-96
					 (emergency); Amended at 14 Ok Reg 252, eff 10-24-96 (emergency); Amended at 14
					 Ok Reg 1780, eff 5-27-97; Amended at 14 Ok Reg 3077, eff 7-1-97 (emergency);
					 Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 3413, eff 7-1-99
					 (emergency); Amended at 17 Ok Reg 805, eff 7-16-99 (emergency); Amended at 17
					 Ok Reg 1204, eff 5-11-00; Amended at 17 Ok Reg 3469, eff 8-1-00 (emergency);
					 Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-02;
					 Amended at 8 Ok Reg 59, eff 5-1-05 (emergency); Amended at 23 Ok Reg 1354, eff
					 5-25-06; Revoked at 24 Ok Reg 317, eff 12-1-06 (emergency); Revoked at 24 Ok
					 Reg 905, eff 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.1 - Outpatient hospital services

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Hospitals providing outpatient hospital services are required to meet the same
				  requirements that apply to the Oklahoma Health Care Authority (OHCA)
				  contracted, non-hospital providers performing the same services. Outpatient
				  services performed outside the hospital facility are not reimbursed as hospital
				  outpatient services.
(b) Covered
				  outpatient hospital services must meet all the criteria listed in (1) through
				  (4) of this subsection.
(1) The care is
				  directed by a physician or dentist.
(2) The care is medically
				  necessary.
(3) The member is not an
				  inpatient [refer to Oklahoma Administrative Code (OAC)
				  317:30-5-41]
				  .
(4) The service is provided in an
				  approved hospital facility.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.2 - Blood and blood fractions

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for blood and blood fractions and the
					 administration of blood and blood fractions when these products are required
					 for the treatment of a congenital or acquired disease of the blood and not
					 available from another source.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.3 - Chemotherapy and radiation therapy

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for charges incurred for the administration
					 of chemotherapy for the treatment of medically necessary and medically approved
					 procedures. Payment for radiation therapy is limited to the treatment of proven
					 malignancies and benign conditions appropriate for sterotactic radiosurgery
					 (e.g., gamma knife).
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.4 - Clinic/treatment room services; urgent care

Current through Vol. 41, No. 20, July 1, 2024
(a) An outpatient hospital clinic is a
				  non-emergency service providing diagnostic, preventive, curative and
				  rehabilitative services on a scheduled basis.
(b) Urgent care payment is made for services
				  provided in non-emergency clinics operated by a hospital. This payment does not
				  include the professional charges of the treating physician, nurse practitioner,
				  physician assistant or charges for diagnostic testing. A facility charge is
				  also allowed when drug and/or blood are administered outpatient.
(c) Urgent Care services will not require a
				  referral for SoonerCare Choice members however other claims will deny without a
				  referral.
(d) Adults are limited to
				  four clinic visits per month.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.5 - Diagnostic testing therapeutic services

Current through Vol. 41, No. 20, July 1, 2024
(a) Reimbursement is made for diagnostic
				  testing to diagnose a disease or medical condition.
(b) Separate payment may be made for
				  ancillary services that are not covered as an integral part of a facility
				  fee.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.6 - Dialysis

Current through Vol. 41, No. 20, July 1, 2024
Payment for dialysis is made at the Medicare prospective
					 payment system wage adjusted base rate. This rate includes all services which
					 Medicare has established as an integral part of the dialysis procedure. The
					 physician is reimbursed separately.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff 5-11-07; Amended at
					 28 Ok Reg 2329, eff 7-13-11 (emergency); Amended at 29 Ok Reg 1106, eff
					 6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.7 - Emergency department (ED) care/services

Current through Vol. 41, No. 20, July 1, 2024
Emergency department care must:
(1) Be provided in a hospital with a designated emergency department; and
(2) Provide direct patient care, including patient assessment, monitoring, and treatment by hospital medical personnel such as physicians, nurses, or lab and x-ray technicians.
(A) Medical records must document the emergency diagnosis and the extent of direct patient care.
(B) Emergency department care does not include unattended waiting time.
(C) Emergency services are covered for a medical emergency. This means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
(i) Placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or continuation of severe pain;
(ii) serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or death.
(D) Labor and delivery is a medical emergency, if it meets this definition.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.7 - Emergency department (ED) care/services

Current through Vol. 41, No. 20, July 1, 2024
Emergency department care must:
(1) Be provided in a hospital with a
				  designated emergency department; and
(2) Provide direct patient care, including
				  patient assessment, monitoring, and treatment by hospital medical personnel
				  such as physicians, nurses, or lab and x-ray technicians.
(A) Medical records must document the
				  emergency diagnosis and the extent of direct patient care.
(B) Emergency department care does not
				  include unattended waiting time.
(C) Emergency services are covered for a
				  medical emergency. This means a medical condition manifesting itself by acute
				  symptoms of sufficient severity (including severe pain) such that a prudent
				  layperson, who possesses an average knowledge of health and medicine, could
				  reasonably expect the absence of immediate medical attention to result in:
(i) Placing the physical or mental health of
				  the individual (or, with respect to a pregnant woman, the health of the woman
				  or her unborn child) in serious jeopardy; or continuation of severe
				  pain;
(ii) serious impairment to
				  bodily functions; serious dysfunction of any bodily organ or part; or
				  death.
(D) Labor and
				  delivery is a medical emergency, if it meets this definition.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.8 - Hearing and speech therapy

Current through Vol. 41, No. 20, July 1, 2024
Payment is covered for hearing and speech services,
					 including evaluations, for children when prior authorized.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.9 - Infusions/injections

Current through Vol. 41, No. 20, July 1, 2024
Intramuscular, subcutaneous or intravenous injections and
					 intravenous (IV) infusions are covered when medically necessary and not
					 considered a compensable part of the procedure.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.10 - Laboratory

Current through Vol. 41, No. 20, July 1, 2024
For laboratory policies please refer to Part 7,
					 Laboratories (Independent, Physician, And Hospital), of this
					 Chapter.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.11 - Observation/treatment

Current through Vol. 41, No. 20, July 1, 2024
(a) Payment is made
				  for the use of a treatment room associated with outpatient observation
				  services. Observation services must be ordered by a physician or other
				  individual authorized by state law. Observation services are furnished by the
				  hospital on the hospital's premises and include use of the bed and periodic
				  monitoring by hospital staff. Observation services must include a minimum of
				  eight (8) hours of continuous care. Outpatient observation services are not
				  covered when they are provided:
(1) On the
				  same day as an emergency department visit.
(2) Prior to an inpatient admission, as those
				  observation services are considered part of the inpatient DRG.
(3) For the convenience of the member,
				  member's family or provider.
(4)
				  When specific diagnoses are not present on the claim.
(5) As part of another service, i.e. for post
				  operative monitoring; recovery after diagnostic testing or concurrently with
				  therapeutic services such as chemotherapy.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.12 - Physical therapy

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for preauthorized outpatient physical
					 therapy, including evaluations, for children.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.13 - Radiology

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for the technical component of outpatient
					 radiation therapy and compensable x-ray procedures.
(1)
Mammograms.
Medically
				  necessary screening mammography is a covered benefit. Additional follow-up
				  mammograms are covered when medically necessary.
(2)
Ultrasounds.
Ultrasounds for
				  obstetrical care are paid in accordance with provisions found at OAC
				  317:30-5-22(b)(2)(A)
				  -(C).
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.15 - Outpatient hospital services for members infected with tuberculosis

Current through Vol. 41, No. 20, July 1, 2024
Outpatient hospital services are covered for members
					 infected with tuberculosis. Coverage includes, but may not be limited to,
					 outpatient hospital visits, laboratory work and x-rays.
(1) Services to members infected with TB are
				  not limited to the scope of the SoonerCare program; however, prior
				  authorization is required for services that exceed the scope of coverage under
				  SoonerCare.
(2) Drugs prescribed
				  for the treatment of TB not in accordance with OAC
				  317:30-3-46
				  require prior authorization by the OHCA Pharmacy Helpdesk using form "Petition
				  for TB Related Therapy."
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.16 - Related services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Ambulance.
Ambulance services furnished by the facility are
				  covered separately if otherwise compensable under the SoonerCare
				  program.
(b)
Home health
				  care.
Hospital-based home health providers must be Medicare certified
				  and have a current Home Health Agency contract with the Oklahoma Health Care
				  Authority (OHCA). For home health services, a qualified provider must conduct
				  and document a face-to-face encounter with the member in accordance with
				  provisions of
				  42 Code of Federal Regulations (C.F.R.) §
											440.70. Refer to Oklahoma Administrative Code
				  (OAC)
				  317:30-5-546
				  and OAC
				  317:30-5-547
				  for additional policy related to coverage and reimbursement for home health
				  care services.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff 5-11-07; Amended at
					 28 Ok Reg 511, eff 1-6-11 (emergency); Amended at 28 Ok Reg 1489, 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 3 - HOSPITALS › Section 317:30-5-42.17 - Non-covered services

Current through Vol. 41, No. 20, July 1, 2024
In addition to the general program exclusions [Oklahoma
					 Administrative Code (OAC)
					 317:30-5-2(a)(2)]
					 the following are excluded from coverage:
(1) Inpatient admission for diagnostic
				  studies that could be performed on an outpatient basis.
(2) Procedures that result in sterilization
				  which do not meet the guidelines set forth in this Chapter.
(3) Reversal of sterilization procedures for
				  the purposes of conception are not covered.
(4) Medical services considered experimental
				  or investigational. For more information regarding coverage of clinical trials,
				  see OAC 317:30-3-57.1.
(5) Payment
				  for removal of benign skin lesions for adults.
(6) Visual aids.
(7) Charges incurred while the member is in a
				  skilled nursing or swing bed.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff 5-11-07; Amended at
					 27 Ok Reg 294, eff 11-3-09 (emergency); Amended at 27 Ok Reg 1439, eff
					 6-11-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.18 - Coverage for children

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Services, deemed medically necessary and allowable under federal Medicaid
				  regulations, may be covered under the EPSDT/OHCA Child Health program even
				  though those services may not be part of the Oklahoma Health Care Authority
				  SoonerCare program. Such services must be prior authorized.
(b) Federal Medicaid regulations also require
				  the State to make the determination as to whether the service is medically
				  necessary and do not require the provision of any items or services that the
				  State determines are not safe and effective or which are considered
				  experimental. For more information regarding experimental or investigational
				  including clinical trials, see Oklahoma Administrative Code 317:30-3-57.1.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.19 - 340B Drug Discount Program

Current through Vol. 41, No. 20, July 1, 2024
For 340B Drug Discount Program guidelines refer to section
					 317:30-5-87.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.20 - High-investment drugs - outpatient hospitals

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority (OHCA)
				  designates certain high-investment drugs to be reimbursed separately pursuant
				  to the Oklahoma Medicaid State Plan for members receiving services at an
				  outpatient hospital.
(b) The list
				  of OHCA-designated high-investment drugs is set forth on the Pharmacy page of
				  the OHCA website, which is available at
https://okhca.org
. This list may be updated as
				  deemed necessary.
(c) All
				  high-investment drugs require prior authorization [refer to Oklahoma
				  Administrative Code (OAC)
				  317:30-3-31]
				  , and the outpatient hospital stay continues to be subject to applicable
				  medical necessity criteria requirements [refer to OAC
				  317:30-3-1(f)]
				  .
(d) OHCA-designated
				  high-investment drugs provided to eligible members, when treated in
				  out-of-state outpatient hospitals, may be reimbursed in the same manner as
				  in-state hospitals. Out-of-state outpatient hospitals must meet applicable
				  out-of-state conditions of payment set forth in OAC
				  317:30-3-89 through
				  317:30-3-92,
				  and in the Oklahoma Medicaid State Plan.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-43 - Vocational Rehabilitation coverage [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 3469, eff 8-1-00 (emergency); Revoked at 18 Ok
					 Reg 1130, eff 5-11-01
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-44 - Medicare eligible individuals

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to hospitals for services to Medicare
					 eligible individuals as set forth in this section.
(1) Claims filed with Medicare automatically
				  cross over to OHCA. The explanation of Medicare Benefits (EOMB) reflects a
				  message that the claim was referred to SoonerCare. If such a message is not
				  present, a claim for coinsurance and deductible must be filed with the OHCA
				  within 90 days of the date of Medicare payment and within one year of the date
				  of service in order to be considered timely filed.
(2) If payment is denied by Medicare and the
				  service is a SoonerCare covered service, mark the claim "denied by Medicare"
				  and attach the Medicare EOMB showing the reason for denial.
(3) In certain circumstances, some claims do
				  not automatically "cross over". Providers must file a claim for coinsurance
				  and/or deductible to SoonerCare within 90 days of the Medicare payment and
				  within one year from the date of service.
(4) For individuals who have exhausted
				  Medicare Part A benefits, claims must be accompanied by a statement from the
				  Medicare Part A intermediary showing the date benefits were exhausted.
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 2134, eff 6-27-02; Amended at 19 Ok
					 Reg 2938, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03;
					 Amended at 25 Ok Reg 648, eff 1-1-08 (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 3 - HOSPITALS › Section 317:30-5-45 - Psychiatric hospitals - inpatient services for persons age 65 and over [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 593, eff 11-21-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Amended at 17 Ok Reg 805, eff 7-16-99 (emergency);
					 Amended at 17 Ok Reg 1204, eff 5-11-00; Revoked at 17 Ok Reg 3469, eff 8-1-00
					 (emergency); Revoked at 18 Ok Reg 1130, eff
					 5-11-01
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-46 - Psychiatric hospitals and residential psychiatric treatment facilities - inpatient services for persons under age 21 [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 593, eff 11-21-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Amended at 14 Ok Reg 258, eff 8-5-96 (emergency);
					 Amended at 14 Ok Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 3784, eff 7-1-98
					 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 17 Ok Reg 805,
					 eff 7-1-99 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Revoked at 17
					 Ok Reg 3469, eff 8-1-00 (emergency); Revoked at 18 Ok Reg 1130, eff
					 5-11-01
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47 - Reimbursement for inpatient hospital services

Current through Vol. 41, No. 20, July 1, 2024
Reimbursement will be made for inpatient hospital services in the following manner:
(1) Covered inpatient services provided to eligible SoonerCare members admitted to in-state acute care and critical access hospitals will be reimbursed the lesser of the billed charges or the Diagnosis Related Group (DRG) amount. In addition to the billed charges or DRG payment, whichever is less, an outlier payment may be made to the hospital for very high cost stays. Additional outlier payment is applicable if either the amount billed by the hospital or DRG payment, whichever applies, is less than a threshold amount of the hospital cost. Each inpatient hospital claim is tested to determine whether the claim qualified for a cost outlier payment. Payment is equal to a percentage of the cost after the threshold is met.
(2) The lesser of the billed charges or DRG amount and outlier, if applicable, represent full reimbursement for all non-physician services provided during the inpatient stay. Payment includes but is not limited to:
(A) Laboratory services;
(B) Prosthetic devices, including pacemakers, lenses, artificial joints, cochlear implants, implantable pumps;
(C) Technical component on radiology services;
(D) Transportation, including ambulance, to and from another facility to receive specialized diagnostic and therapeutic services;
(E) Pre-admission diagnostic testing performed within seventy-two (72) hours of admission; and
(F) Organ transplants.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47 - Reimbursement for inpatient hospital services

Current through Vol. 41, No. 20, July 1, 2024
Reimbursement will be made for inpatient hospital services
					 in the following manner:
(1) Covered
				  inpatient services provided to eligible SoonerCare members admitted to in-state
				  acute care and critical access hospitals will be reimbursed the lesser of the
				  billed charges or the Diagnosis Related Group (DRG) amount. In addition to the
				  billed charges or DRG payment, whichever is less, an outlier payment may be
				  made to the hospital for very high cost stays. Additional outlier payment is
				  applicable if either the amount billed by the hospital or DRG payment,
				  whichever applies, is less than a threshold amount of the hospital cost. Each
				  inpatient hospital claim is tested to determine whether the claim qualified for
				  a cost outlier payment. Payment is equal to a percentage of the cost after the
				  threshold is met.
(2) The lesser of
				  the billed charges or DRG amount and outlier, if applicable, represent full
				  reimbursement for all non-physician services provided during the inpatient
				  stay. Payment includes but is not limited to:
(A) Laboratory services;
(B) Prosthetic devices, including pacemakers,
				  lenses, artificial joints, cochlear implants, implantable pumps;
(C) Technical component on radiology
				  services;
(D) Transportation ,
				  including ambulance, to and from another facility to receive specialized
				  diagnostic and therapeutic services;
(E) Pre-admission diagnostic testing
				  performed within seventy-two (72) hours of admission; and
(F) Organ transplants.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.1 - Reimbursement for newborn screening services provided by the OSDH

Current through Vol. 41, No. 20, July 1, 2024
Newborn screening performed by the Oklahoma State
					 Department of Health in accordance with State Law is excluded from the
					 inpatient DRG payment.
Added at 20 Ok Reg
					 1863, eff 4-30-03 (emergency); Added at 21 Ok Reg 1324, eff 5-27-04; Amended at
					 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.2 - Disproportionate share hospitals (DSH)

Current through Vol. 41, No. 20, July 1, 2024
Payment will be made to hospitals qualifying for
					 Disproportionate Share Hospital adjustments pursuant to the methodology
					 described in the Oklahoma Title XIX Inpatient Hospital State
					 Plan.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff 5-25-06; Amended at
					 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.3 - Indirect medical education (IME) adjustment

Current through Vol. 41, No. 20, July 1, 2024
Payment will be made to hospitals qualifying for Indirect
					 Medical Education payment adjustments pursuant to the methodology described in
					 the Oklahoma Title XIX Inpatient Hospital State Plan.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff 5-25-06; Amended at
					 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.4 - Direct medical education payment adjustment

Current through Vol. 41, No. 20, July 1, 2024
Payment will be made to hospitals qualifying for Direct
					 Medical Education payment adjustments pursuant to the methodology described in
					 the Oklahoma Title XIX Inpatient Hospital State Plan.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff 5-25-06; Amended at
					 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.5 - Critical Access Hospitals

Current through Vol. 41, No. 20, July 1, 2024
Critical Access Hospitals (CAHs) are rural public or
					 non-profit hospitals which have been certified by Medicare as a Critical Access
					 Hospital. The facility must provide documentation to be determined eligible for
					 the CAH peer group.
Added at 23 Ok Reg
					 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff
					 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-47.6 - High-investment drugs - inpatient hospitals

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority (OHCA)
				  designates certain high-investment drugs to be reimbursed separately pursuant
				  to the Oklahoma Medicaid State Plan for members receiving services at an
				  inpatient hospital.
(b) The list of
				  OHCA-designated high-investment drugs is set forth on the Pharmacy page of the
				  OHCA website, which is available at
https://okhca.org
. This list may be updated as
				  deemed necessary.
(c) All
				  high-investment drugs require prior authorization [refer to Oklahoma
				  Administrative Code (OAC)
				  317:30-3-31]
				  , and the inpatient hospital stay continues to be subject to applicable medical
				  necessity criteria requirements [refer to OAC
				  317:30-3-1(f)]
				  .
(d) OHCA-designated
				  high-investment drugs provided to eligible members, when treated in
				  out-of-state inpatient hospitals, may be reimbursed in the same manner as
				  in-state hospitals. Out-of-state inpatient hospitals must meet applicable
				  out-of-state conditions of payment set forth in OAC
				  317:30-3-89 through
				  317:30-3-92,
				  and in the Oklahoma Medicaid State Plan.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-48 - Cost reports [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 15 Ok Reg 3784, eff 7-1-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99; Revoked at 23 Ok Reg 239, eff 10-3-05 (emergency);
					 Revoked at 23 Ok Reg 1346, eff 5-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-49 - Reporting suspected abuse

Current through Vol. 41, No. 20, July 1, 2024
Instances of child abuse and/or neglect are to be reported
					 in accordance with State law. Any person suspecting child abuse or neglect
					 shall immediately report it to the Oklahoma Department of Human Services
					 (OKDHS) hotline, at 1-800-522-3511. Any person suspecting abuse, neglect, or
					 exploitation of a vulnerable adult shall immediately report it to the local
					 OKDHS County Office, municipal or county law enforcement authorities, or, if
					 the report occurs after normal business hours, the OKDHS hotline. 10A O.S.
					 § 1-2-101; 43A O.S. § 10-104. Health care professionals who are
					 requested to report incidents of domestic abuse by adult victims with legal
					 capacity shall promptly make a report to the nearest law enforcement agency,
					 per 22 O.S. §
										58.
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 26 Ok Reg 2081, eff
					 6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-50 - Abortions

Current through Vol. 41, No. 20, July 1, 2024
(a) Payment is made
				  only for abortions in those instances where the abortion is necessary due to a
				  physical disorder, injury or illness, including a life-endangering physical
				  condition caused by or arising from the pregnancy itself, that would, as
				  certified by a physician, place the woman in danger of death unless an abortion
				  is performed, or where the pregnancy is the result of an act of rape or incest.
				  SoonerCare coverage for abortions to terminate pregnancies that are the result
				  of rape or incest are considered to be medically necessary services and federal
				  financial participation is available specifically for these services.
(1) For abortions necessary due to a physical
				  disorder, injury or illness, including a life-endangering physical condition
				  caused by or arising from the pregnancy itself, that would place the woman in
				  danger of death unless an abortion is performed, the physician must complete
				  the Certification for Medicaid Funded Abortion and certify in writing that the
				  abortion is being performed due to a physical disorder, injury or illness,
				  including a life-endangering physical condition caused by or arising from the
				  pregnancy itself, that would place the woman in danger of death unless an
				  abortion is performed. The patient's name and address must be included in the
				  certification and the certification must be signed and dated by the physician.
				  The certification must be attached to the claim.
(2) For abortions in cases of rape or incest,
				  there are two requirements for the payment of a claim. First, the physician
				  must fully complete the Certification for Medicaid Funded Abortion. Second, the
				  patient must have made a police report or counselor's report of the rape or
				  incest. In cases where an official report of the rape or incest is not
				  available, the physician must certify in writing and provide documentation that
				  in his or her professional opinion, the patient was unable, for physical or
				  psychological reasons, to comply with the requirement. The statement explains
				  the reason the rape or incest was not reported. The patient's name and address
				  must be included in the certification and the certification must be signed and
				  dated by the physician and the patient . In cases where a physician provides
				  certification and documentation of a patient's inability to file a report, the
				  Oklahoma Health Care Authority (OHCA) will perform a prepayment review of all
				  records to ensure there is sufficient documentation to support the physician's
				  certification.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-51 - Elective sterilizations

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Payment is made to hospitals for elective sterilizations performed in behalf of
				  eligible individuals if all of the following circumstances are met:
(1) The patient must be at least 21 years of
				  age at the time the consent form is signed,
(2) The patient must be mentally
				  competent,
(3) A properly completed
				  Federally mandated consent for sterilization form is attached to the claim,
				  and
(4) The form is signed by the
				  patient at least 30 days, but not more than 180 days prior to the
				  surgery.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-52 - Hysterectomies

Current through Vol. 41, No. 20, July 1, 2024
A hysterectomy performed for purposes of sterilization or
					 family planning is not compensable. Payment is made to hospitals for
					 therapeutic hysterectomies only when one of the following circumstances is
					 met.
(1) A properly completed
				  hysterectomy acknowledgement is attached to the claim form. The acknowledgement
				  must clearly state that the patient or her representative was informed, orally
				  and in writing, prior to the surgery that she would be rendered permanently
				  incapable of reproduction. The 30 day waiting period which applies to elective
				  sterilizations does not apply to therapeutic hysterectomies.
(2) The surgeon must certify in writing that
				  the patient was sterile prior to the surgery. The reason for the sterility,
				  i.e., post-menopausal, previous tubal ligation, etc. must be given.
(3) The surgeon must certify that the surgery
				  was performed in an emergency, life endangering situation. The circumstances
				  must be given. A hysterectomy acknowledgement form may be signed by the patient
				  and dated after the surgery as long as the acknowledgement meets all other
				  requirements. The patient must acknowledge in the form that prior to surgery
				  she was advised orally and in writing that she would be rendered sterile as a
				  result of the surgery.
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 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-53 - Newborn care

Current through Vol. 41, No. 20, July 1, 2024
The county Department of Human Services office where the
					 mother resides must be notified in writing within five days of the child's
					 birth in order for an individual person code to be assigned to the newborn. A
					 claim may then be filed for nursery charges for the baby under the case number
					 and the baby's name and assigned person code. Nursery charges billed on the
					 mother's person code will be denied. Providers must use Form FSS-NB-1 to notify
					 the county DHS office of the child's birth. Copies of the form may be obtained
					 at the county DHS office.
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 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-54 - Hospital rate appeals [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 3585, eff 7-16-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; 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 3 - HOSPITALS › Section 317:30-5-55 - Residential psychiatric treatment facility rate appeals [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 3585, eff 7-16-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; 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 3 - HOSPITALS › Section 317:30-5-56 - Utilization review

Current through Vol. 41, No. 20, July 1, 2024
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. In
					 addition to the random sample of all admissions, retrospective review policy
					 includes the following:
(1) Hospital
				  stays less than three days in length will be reviewed for medical necessity and
				  appropriateness of care. (Discharges involving healthy mother and healthy
				  newborns may be excluded from this review requirement.) If it is determined
				  that the inpatient stay was unnecessary or inappropriate, the prospective
				  payment for the inpatient stay will be denied.
(2) Cases which indicate transfer from one
				  acute care hospital to another will be monitored to help ensure that payment is
				  not made for inappropriate transfers.
(3) Readmissions occurring within 30 days of
				  prior acute care admission for a related condition will be reviewed to
				  determine medical necessity and appropriateness of care or whether the
				  readmission was potentially preventable. If it is determined that either or
				  both admissions were unnecessary or inappropriate or potentially preventable,
				  payment for either or both admissions may be denied. Such review may be focused
				  to exempt certain cases at the sole discretion of the OHCA.
Added at 24 Ok Reg
					 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff
					 5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-58 - Supplemental Hospital Offset Payment Program

Current through Vol. 41, No. 20, July 1, 2024
(a)
Purpose.
The Supplemental
				  Hospital Offset Payment Program (SHOPP) is a hospital assessment fee that is
				  eligible for federal matching funds when used to reimburse SoonerCare services
				  in accordance with Section
				  3241.1 of
				  Title 63 of the Oklahoma Statutes (O.S.).
(b)
Definitions.
The following
				  words and terms, when used in this Section have the following meaning, unless
				  the context clearly indicates otherwise:
(1)
"Base Year"
means a hospital's fiscal year ending in 2009, as
				  reported in the Medicare Cost Report or as determined by the Oklahoma Health
				  Care Authority (OHCA) if the hospital's data is not included in a Medicare Cost
				  Report.
(2)
"Directed
				  payments"
means payment arrangements allowed under 42 Code of Federal
				  Regulations (C.F.R.) Section (§) 438.6(c) that permit states to direct
				  specific payments made by managed care plans to providers under certain
				  circumstances and can assist states in furthering the goals and priorities of
				  their Medicaid programs.
(3)
"Fee"
means supplemental hospital offset assessment pursuant to
				  Section(§) 3241.1 of Title 63 of the O.S.
(4)
"Hospital"
means an
				  institution licensed by the State Department of Health as a hospital pursuant
				  to § 1-701.1 of Title 63 of the O.S. maintained primarily for the
				  diagnosis, treatment, or care of patients.
(5)
"Hospital Advisory
				  Committee"
means the Committee established for the purposes of advising
				  the OHCA and recommending provisions within and approval of any state plan
				  amendment or waiver affecting the Supplemental Hospital Offset Payment
				  Program.
(6)
"NET hospital
				  patient revenue"
means the gross hospital revenue as reported on
				  Worksheet G-2 (Columns 1 and 2, Lines "Total inpatient routine care services",
				  " Ancillary services", "Outpatient services") of the Medicare cost report,
				  multiplied by hospital's ratio of total net to gross revenue, as reported on
				  Worksheet G-3(Column 1, Line 3) "Net patient revenues" and Worksheet G-2 (Part
				  I, Column 3, Line "Total patient revenues").
(7)
"Medicare cost report"
means
				  the hospital cost report, Form CMS-2552-96 or subsequent versions.
(8)
"Upper payment limit (UPL)"
means the maximum ceiling imposed by
				  42 C.F.R.
				  §§
												447.272 and
				  447.321
				  on hospital Medicaid reimbursement for inpatient and outpatient services, other
				  than to hospitals owned or operated by state government.
(9)
"Upper payment limit gap"
means the difference between the upper payment limit and SoonerCare payments
				  not financed using hospital assessments.