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 35 - RURAL HEALTH CLINICS › Section 317:30-5-354 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
					 shall have the following meaning, unless the context clearly indicates
					 otherwise:
"APRN"
means advanced practice registered
					 nurse.
" C.F.R."
means the U.S. Code of Federal
					 Regulations.
"CLIA"
means the Clinical Laboratory
					 Improvement Amendments.
"CMS"
means the Centers for Medicare and
					 Medicaid Services.
"CNM"
means certified nurse midwife.
"Core services"
means outpatient services that
					 may be covered when furnished to a patient at the rural health clinic (RHC) or
					 other location, including the patient's place of residence.
"CP"
means clinical psychologist.
"CPT"
means current procedural terminology.
"CSW"
means clinical social worker.
"EPSDT"
means the Early and Periodic
					 Screening, Diagnostic and Treatment program for members under twenty-one (21).
"FFS"
means the current OHCA's fee-for-service
					 reimbursement rate.
"HCPCS"
means Healthcare Common Procedure
					 Coding System.
"OAC"
means the Oklahoma Administrative Code.
"OHCA"
means the Oklahoma Health Care
					 Authority.
"Other ambulatory services"
means other
					 outpatient health services covered under the Oklahoma Medicaid State Plan other
					 than core services.
"PA"
means physician assistant.
"Physician"
means:
(A) A doctor of medicine or osteopathy legally authorized
					 to practice medicine and surgery by the State in which the function is
					 performed or who is a licensed physician employed by the Public Health Service;
(B) Within limitations as to the specific services
					 furnished, a doctor of dentistry or dental, a doctor of optometry, or a doctor
					 of podiatry.
"Physicians' services"
means professional
					 services that are performed by a physician at the RHC (or are performed away
					 from the Center, excluding inpatient hospital services) whose agreement with
					 the RHC provides that he or she will be paid by the RHC for such services.
"PPS"
means prospective payment system
					 all-inclusive per visit rate method specified in the Oklahoma Medicaid State
					 Plan.
"RHC"
means rural health clinic.
"Visit"
means a face-to-face encounter between
					 a clinic patient and a physician, PA, APRN, CNM, CP or CSW whose services are
					 reimbursed under the RHC payment method. Encounters with more than one (1)
					 health care professional and multiple encounters with the same health care
					 professional that take place on the same day and at a single location
					 constitute a single visit, except when the patient, after the first encounter,
					 suffers illness or injury requiring additional diagnosis or treatment.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-355 - Eligible providers and staffing requirements

Current through Vol. 41, No. 20, July 1, 2024
(a)
Eligible providers.
RHCs
				  certified for participation in the Medicare Program are considered eligible for
				  participation in the Medicaid Program. RHC conditions for certification are
				  found in 42 C.F.R. Part 491 . RHCs may be provider-based (i.e., clinics that
				  are an integral part of a hospital, skilled nursing facility, or home health
				  agency that participates in Medicare) or independent (freestanding) and may
				  include Indian Health Clinics. To participate, an RHC must have a current
				  contract on file with the OHCA.
(b)
Staffing requirements.
Eligible providers must follow all staffing
				  and staff responsibilities in accordance with
				  42 C.F.R. §
											491.8. Additional requirements for mid-level
				  practitioners at the clinic include:
(1) A
				  nurse practitioner, a physician assistant, or certified nurse-midwife must be
				  available to furnish patient care services at least fifty percent (50%) of the
				  time the clinic operates.
(2) An
				  existing clinic may request a temporary waiver of these staffing requirements
				  for a one (1) year period, if it demonstrates that it has been unable to hire a
				  physician assistant, nurse-practitioner, or a certified nurse-midwife in the
				  previous ninety (90) day period.
(3) A subsequent request for a waiver cannot
				  be made less than six (6) months after the expiration date of any previous
				  waiver of the mid-level staffing requirements for the clinic.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-355.1 - RHC professional staff

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  RHCs must either directly employ or contract the services of professional staff
				  who is licensed or certified and in good standing in the state in which
				  services are provided. Services must be within the scope of the professional's
				  license or certification for which claims are submitted to OHCA or its
				  designated agent.
(b) Professional
				  staff contracted or employed by the RHC recognized by the OHCA for direct
				  reimbursement are required to individually enroll with the OHCA and will be
				  affiliated with the organization which contracts or employs them. Participating
				  RHCs are required to submit a list of names upon request of all practitioners
				  working within the RHC and a list of all individual OHCA provider numbers.
				  Reimbursement for services rendered at or on behalf of the RHC is made to the
				  organization. Practitioners eligible for direct reimbursement for providing
				  services to a clinic patient outside of the clinic may bill with their
				  individual assigned number if they are not compensated under agreement by the
				  RHC.
(c) Other providers who are
				  not eligible for direct reimbursement may be recognized by the OHCA for the
				  provision and payment of RHC services to an RHC as long as they are licensed or
				  certified in good standing and meet OHCA enrollment requirements.
Added at 13 Ok Reg 397, eff 11-14-95 (emergency) ; Added
						at 13 Ok Reg 1645, eff 5-27-96 ; 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
						141, eff 10-14-98 (emergency) ; Amended at 16 Ok Reg 1429, eff 5-27-99 ;
						Amended at 24 Ok Reg 895, eff 5-11-07 ; Amended at 30 Ok Reg 1164, 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 35 - RURAL HEALTH CLINICS › Section 317:30-5-355.2 - Covered services

Current through Vol. 41, No. 20, July 1, 2024
The Rural Health Center benefit package, as described in
					 42 C.F.R. §
											440.20, consists of RHC services and other
					 ambulatory services.
(1)
RHC
				  services.
RHC services are covered when medically necessary and
				  furnished at the clinic or other outpatient setting, including the member's
				  place of residence, delivered via telehealth, or via audio-only
				  telecommunications pursuant to Oklahoma Administrative Code (OAC)
				  317:30-3-27 and OAC
				  317:30-3-27.1.
(A)
Core services.
RHC "core"
				  services include, but are not limited to:
(i)
				  Services furnished by a physician, Physician Assistant (PA), Advanced Practice
				  Registered Nurse (APRN), Certified Nurse Midwife (CMN), Clinical Psychologist
				  (CP), or Clinical Social Worker.
(ii) Services and supplies incident to
				  services provided by a physician, PA, APRN, CNM, CP, or CSW are covered in
				  accordance with 42 C.F.R
				  §§
													405.2413 and
				  405.2415, if the service or supply
				  is:
(I) Furnished in accordance with State
				  law;
(II) A type commonly furnished
				  in physicians' offices;
(III) A
				  type commonly rendered either without charge or included in the RHC's
				  bill;
(IV) Furnished as an
				  incidental, although integral, part of a physician's professional services, PA,
				  APRN, CNM, CP or CSW; or
(V)
				  Furnished under the direct supervision of a contracted physician PA, APRN, or
				  CNM; and
(VI) Drugs and biologicals
				  which cannot be self-administered or are specifically covered by Medicare law,
				  are included within the scope of RHC services. Drugs and biologicals commonly
				  used in life saving procedures, such as analgesics, anesthetics (local),
				  antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids are not
				  billed separately.
(iii)
				  Visiting nurse services to the homebound are covered if:
(I) The RHC is located in an area in which
				  the Secretary of Health and Human Services has determined there is a shortage
				  of home health agencies;
(II) The
				  services are rendered to members who are homebound;
(III) The member is furnished nursing care on
				  a part-time or intermittent basis by a registered nurse, licensed practical
				  nurse, or licensed vocational nurse who is employed by or receives compensation
				  for the services from the RHC; and
(IV) The services are furnished under a
				  written plan of treatment as required by
				  42 C.F.R §
														405.2416.
(iv) Certain virtual communication
				  services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-355.2 - Covered services

Current through Vol. 41, No. 20, July 1, 2024
The RHC benefit package, as described in
					 42
					 C.F.R. §
											440.20, consists of RHC
					 services and other ambulatory services.
(1)
RHC services.
RHC services
				  are covered when medically necessary and furnished at the clinic or other
				  outpatient setting, including the member's place of residence.
(A)
Core services.
RHC "core"
				  services include, but are not limited to:
(i)
				  Services furnished by a physician, PA, APRN, CNM, CP, or CSW.
(ii) Services and supplies incident to
				  services provided by a physician, PA, APRN, CNM, CP, or CSW are covered in
				  accordance with
				  42 C.F.R
				  §§
													405.2413 and
				  405.2415,
				  if the service or supply is:
(I) Furnished in
				  accordance with State law;
(II) A
				  type commonly furnished in physicians' offices;
(III) A type commonly rendered either without
				  charge or included in the RHC's bill;
(IV) Furnished as an incidental, although
				  integral, part of a physician's professional services, PA, APRN, CNM, CP or
				  CSW; or
(V) Furnished under the
				  direct supervision of a contracted physician PA, APRN, or CNM; and
(VI) Drugs and biologicals which cannot be
				  self-administered or are specifically covered by Medicare law, are included
				  within the scope of RHC services. Drugs and biologicals commonly used in life
				  saving procedures, such as analgesics, anesthetics (local), antibiotics,
				  anticonvulsants, antidotes and emetics, serums and toxoids are not billed
				  separately.
(iii)
				  Visiting nurse services to the homebound are covered if:
(I) The RHC is located in an area in which
				  the Secretary of Health and Human Services has determined there is a shortage
				  of home health agencies;
(II) The
				  services are rendered to members who are homebound;
(III) The member is furnished nursing care on
				  a part-time or intermittent basis by a registered nurse, licensed practical
				  nurse, or licensed vocational nurse who is employed by or receives compensation
				  for the services from the RHC; and
(IV) The services are furnished under a
				  written plan of treatment as required by
				  42 C.F.R §
														405.2416.
(iv) Certain virtual communication services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-356 - Coverage for adults

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to RHCs for adult services as set forth in
					 this Section.
(1)
RHC
				  services.
Payment is made for one (1) encounter per member per day.
				  Payment is also limited to four (4) visits per member per month. This limit may
				  be exceeded if the SoonerCare Choice member has elected the RHC as
				  his/her/their Patient Centered Medical Home/Primary Care Provider. Preventive
				  service exceptions include:
(A)
Obstetrical care.
An RHC should have a written contract with its
				  physician, PA, APRN, or CNM that specifically identifies how obstetrical care
				  will be billed to SoonerCare, in order to avoid duplicative billing situations.
				  The agreement should also specifically identify the physician's compensation
				  for RHC and other ambulatory services.
(i) If
				  the clinic compensates the physician, PA, APRN, or CNM to provide obstetrical
				  care, then the clinic must bill the SoonerCare program for each prenatal visit
				  using the appropriate CPT evaluation and management codes.
(ii) If the clinic does not compensate its
				  practitioners to provide obstetrical care, then the independent practitioner
				  must bill the OHCA for prenatal care according to the global method described
				  in the SoonerCare provider specific rules for physicians, PAs, APRNs and CNMs
				  (refer to OAC
				  317:30-5-22)
				  .
(iii) Under both billing methods,
				  payment for prenatal care includes all routine or minor medical problems. No
				  additional payment is made to the prenatal provider except in the case of a
				  major illness distinctly unrelated to pregnancy.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-357 - Coverage for children

Current through Vol. 41, No. 20, July 1, 2024
RHC services and other ambulatory services for children
					 include the same services as for adults. Medical review will be required for
					 additional visits for children. Additional services for children include:
(1) EPSDT services are covered for
				  eligible members under twenty-one (21) years of age in accordance with OAC
				  317:30-3-65.
				  An EPSDT exam performed by an RHC must be billed on the appropriate claim form
				  with the appropriate preventive medicine procedure code from the CPT manual .
				  If an EPSDT screening is billed, an RHC encounter should not be billed on the
				  same day. Refer to OAC
				  317:30-3-65
				  through
				  317:30-3-65.12.
(2) Under EPSDT, coverage is
				  allowed for visual screenings and eyeglasses to correct visual defects. Payment
				  is limited to two (2) glasses per year. Any glasses beyond this limit must be
				  prior authorized and determined to be medically necessary.
(3) An EPSDT screening is considered a
				  comprehensive examination. A provider billing the Medicaid program for an EPSDT
				  screening may not bill any other visits for that patient on that same day. It
				  is expected that the screening provider will perform necessary treatment as
				  part of the screening charge. Additional services such as tests, immunizations,
				  etc., required at the time of screening may be billed independently from the
				  screening.
(4) The administration
				  fee for immunizations should be billed if provided at the same time as a
				  scheduled EPSDT examination.
(5)
				  Payment may be made directly to the RHC for the professional services of
				  physician assistants performing EPSDT screenings within the certified RHC. The
				  claim form must include the signature of the supervising physician.
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 397, eff 11-14-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Amended at 17 Ok Reg 2368, eff 6-26-00; Amended at 19 Ok
					 Reg 2134, eff 6-27-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-358 - 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 19 Ok Reg 2134, eff 6-27-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-359 - Claims for Medicare eligible recipients

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to rural health clinics utilizing the
					 Medicaid allowable for comparable services.
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 2922, eff 7-1-02 (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 35 - RURAL HEALTH CLINICS › Section 317:30-5-359.1 - Cost reports

Current through Vol. 41, No. 20, July 1, 2024
(a) Provider-based
				  Rural Health Clinics (RHC) are required to report each RHC on a separate clinic
				  line cost center on the Medicare Cost Report (HCFA 2552). A copy of the HCFA
				  2552, including the Medicaid Supplemental Worksheet S-2, is submitted to the
				  Oklahoma Health Care Authority (OHCA) as part of the year-end cost report
				  process of the parent hospital.
(b) Independent RHCs are required to submit
				  to the OHCA a completed copy of the Medicare Cost Report for the annual cost
				  reporting period (HCFA 222-92) within the due date for filing the cost report
				  to the fiscal intermediary. Preventive services, i.e., prenatal, EPSDT and
				  family planning visits, should not be counted in total visits in the Medicare
				  cost report. The associated cost for the RHC services covered by Medicaid only
				  should be reported as a non-reimbursable cost on the clinic's Medicare cost
				  report.
Added at 13 Ok Reg
					 397, eff 11-14-95 (emergency); Added at 13 Ok Reg 1645, eff
					 5-27-96
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-359.2 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a)
Provider-based clinics.
Payments for provider-based clinics will
				  be made for RHC "core" services based on an all-inclusive visit fee established
				  by one of the following:
(1) An interim rate
				  established by calculating a statewide average rate for RHCs in the state; and
(2) The statewide average rate
				  will be updated annually by the increase in the Medicare Economic Index (MEI);
				  or
(3) An Alternative Payment
				  Methodology (APM) established by the RHC periodic rate notification from the
				  Medicare Fiscal Intermediary. In order to receive this rate, the RHC must
				  submit a copy of the periodic rate notification letter for its most recent full
				  cost reporting year received from the fiscal intermediary to the state. The APM
				  rate cannot be lower than mentioned above in (a)(1) or (a)(2).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-360 - Payment rates [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 13 Ok Reg 397, eff 11-14-95 (emergency); Revoked at 13 Ok
					 Reg 1645, eff 5-27-96
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-362 - Documentation of records

Current through Vol. 41, No. 20, July 1, 2024
All services offered by a rural health clinic are to be
					 furnished in accordance with applicable Federal and State laws and regulations.
					 These requirements include written policies as to the description of the
					 services the clinic furnishes directly and also those services provided by
					 agreement or arrangement.
(1) a
				  clinical record system must be maintained in accordance with written policies
				  and procedures, and be available to onsite reviewers upon request.
(2) records necessary to disclose the extent
				  of services the provider furnishes to recipients, including those records as
				  just described, and any information regarding payments claimed by the provider
				  for furnishing services must be retained for a period of six years.
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 397, eff 11-14-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 35 - RURAL HEALTH CLINICS › Section 317:30-5-363 - 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 37 - ADVANCED PRACTICE REGISTERED NURSE › Section 317:30-5-375 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
(a) The advanced
				  practice registered nurse (APRN) must:
(1) Be
				  licensed and in good standing in the state in which services are provided;
(2) Have completed an accredited
				  graduate level advanced practice registered nursing education program approved
				  by the board of nursing in the state in which services are provided; and
(3) Possess a current national
				  certification by a national certifying body recognized by the board of nursing
				  in the state in which services are provided.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 37 - ADVANCED PRACTICE REGISTERED NURSE › Section 317:30-5-376 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to advanced practice registered nurses
					 (APRNs) as set forth in this Section.
(1)
Adults.
Payment for adults
				  is made for primary care health services, within the scope of practice of an
				  APRN and within the scope of the Oklahoma Health Care Authority (OHCA) medical
				  programs.
(2)
Children.
Payment for children is made for primary care health
				  services, within the scope of practice of an APRN, to members under twenty-one
				  (21) years of age, including Early and Periodic Screening, Diagnostic and
				  Treatment (EPSDT) screening services.
(A)
				  Payment is made to eligible providers for EPSDT services to members under
				  twenty-one (21) years of age . Specific guidelines for the EPSDT program
				  including the periodicity schedule are found in Oklahoma Administrative Code
				  (OAC)
				  317:30-3-65
				  through
				  317:30-3-65.12.
(B) Comprehensive screening
				  examinations are to be performed by a provider qualified under State law to
				  furnish primary health care services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 37 - ADVANCED PRACTICE REGISTERED NURSE › Section 317:30-5-377 - Billing instructions [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 2397, eff 2-5-97 (emergency); Amended at 14 Ok
					 Reg 2928, eff 7-11-97; Amended at 16 Ok Reg 141, eff 10-14-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 17 Ok Reg 2368, eff 6-26-00;
					 Revoked at 19 Ok Reg 2134, eff 6-27-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 39 - SKILLED NURSING SERVICES › Section 317:30-5-390 - Home and Community-Based Services waivers for adults with an intellectual disability or certain adults with related conditions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Introduction to waiver
				  services.
Each Home and Community-Based Services (HCBS) waiver that
				  includes services for adults with an intellectual disability or certain adults
				  with related conditions allows payment for home health care services as defined
				  in the waiver approved by the Centers for Medicare and Medicaid Services.
(1) Home health care services are skilled
				  nursing services provided to a member by a registered nurse(RN) or a licensed
				  practical nurse(LPN) that include:
(A) Direct
				  nursing care;
(B) Assessment and
				  documentation of health changes;
(C) Documentation of significant
				  observations;
(D) Maintenance of
				  nursing plans of care;
(E)
				  Medication administration;
(F)
				  Training of the member's health care needs;
(G) Preventive and health care procedures;
				  and
(H) Preparing , analyzing, and
				  presenting nursing assessment information regarding the member.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 39 - SKILLED NURSING SERVICES › Section 317:30-5-391 - Coverage for skilled nursing services

Current through Vol. 41, No. 20, July 1, 2024
(a) All skilled nursing services must be
				  ordered and prescribed by a physician, supported by a nursing plan of care,
				  included in the individual plan as described in Oklahoma Administrative Code
				  (OAC)
				  340:100-5-53 and
				  reflected in the plan of care approved in accordance with OAC
				  340:100-3-33
				  and
				  340:100-3-33.1.
				  For purposes of this Section, a physician is defined as all licensed medical
				  and osteopathic physicians, physician assistants(PAs) and advanced practice
				  registered nurses(APRNs) in accordance with the rules and regulations covering
				  the OHCA's medical care program. Arrangements for waiver skilled nursing
				  services are made through the personal support team with the specific
				  involvement of the assigned Oklahoma Department of Human Services (OKDHS)
				  Developmental Disabilities Services Division (DDSD) registered nurse (RN). The
				  DDSD RN develops a nursing service support plan subject to review and
				  authorization by the DDSD state nursing director or designee.
(b) Skilled nursing services are rendered in
				  such a manner as to provide the service recipient as much autonomy as possible.
(1) Skilled nursing services must be flexible
				  and responsive to changes in the service recipient's needs.
(2) Providers are expected to participate in
				  annual personal support team meetings and other team meetings as required.
(3) Appropriate supervision of
				  skilled nursing services including services provided by licensed practical
				  nurses (LPNs) is provided pursuant to State law and regulatory board
				  requirements.
(4) Individual
				  service providers must be RNs or LPNs currently licensed and in good standing
				  in the state in which services are provided .
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 39 - SKILLED NURSING SERVICES › Section 317:30-5-392 - Description of Skilled Nursing services

Current through Vol. 41, No. 20, July 1, 2024
Types of Skilled Nursing Services in the waiver programs
					 offered by the Oklahoma Department of Human Services' Developmental
					 Disabilities Services Division (DDSD) are:
(1)
Extended Duty Skilled Nursing
				  Care.
Extended Duty Skilled Nursing Care allows a licensed nurse to
				  provide direct services in a community setting up to 24 hours per day.
(A) Extended Duty Skilled Nursing Care must
				  be:
(i) provided only to those service
				  recipients who have health-related issues that require skilled treatment or
				  other intervention by a licensed nurse more frequently than every two
				  hours;
(ii) ordered by a licensed
				  medical physician, osteopathic physician, physician assistant, or advanced
				  practice nurse;
(iii) justified in
				  amount by the review done in accordance with OAC
				  340:100-5-26;
				  and
(iv) documented in the service
				  recipient's Plan of Care.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 39 - SKILLED NURSING SERVICES › Section 317:30-5-393 - Coverage limitations for Skilled Nursing Services

Current through Vol. 41, No. 20, July 1, 2024
(a) Extended Duty Skilled Nursing Care cannot
				  exceed three eight-hour shifts in a 24-hour period.
(b) Intermittent Skilled Nursing Care is
				  limited to no more than three skilled task site visits in a 24-hour period of
				  time.
(c) Individualized Skilled
				  Nurse Training and Evaluation is reimbursed on the basis of a 15-minute unit of
				  service. No more than 16 units of Individualized Skilled Nurse Training and
				  Evaluation can be provided per month, unless the exception is:
(1) justified in writing by the team in
				  accordance with OAC
				  340:100-3-33.1;
(2) recommended by the DDSD area nurse
				  manager; and
(3) meets the
				  requirements of OAC
				  340:100-3-33.1.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 39 - SKILLED NURSING SERVICES › Section 317:30-5-394 - Diagnosis codes [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95
						(emergency) ; Added at 12 Ok Reg 3131, eff 7-27-95 ; Amended at 16 Ok Reg 3283,
						eff 6-1-99 (emergency) ; Amended at 17 Ok Reg 1204, eff 5-11-00 ; Revoked at 30
						Ok Reg 1169, 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 41 - FAMILY SUPPORT SERVICES › Section 317:30-5-410 - Home and Community-Based Services Waivers for persons with an intellectual disability or certain persons with related conditions

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority (OHCA)
				  administers Home and Community-Based Services (HCBS) Waivers for persons with
				  an intellectual disability and certain persons with related conditions that are
				  operated by the Oklahoma Department of Human Services (OKDHS) Developmental
				  Disabilities Services Division (DDSD). Each waiver allows payment for family
				  support services as defined in the waiver approved by the Centers for Medicare
				  and Medicaid Services (CMS). Waiver services:
(1) when utilized with services normally
				  covered by SoonerCare, other generic services, and natural supports provide for
				  health and developmental needs of members who otherwise would not be able to
				  live in a home or community setting;
(2) are provided with the goal of promoting
				  independence through strengthening the member's capacity for self-care and
				  self-sufficiency;
(3) are centered
				  on the needs and preferences of the member and support the integration of the
				  member within his/her community; and
(4) do not include room and board. The costs
				  associated with room and board must be met by the member.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 41 - FAMILY SUPPORT SERVICES › Section 317:30-5-411 - Coverage

Current through Vol. 41, No. 20, July 1, 2024
All family support services will be included in the
					 member's Individual Plan (IP). Arrangements for care under this program must be
					 made with the member's case manager.
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 24 Ok Reg 879, 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 41 - FAMILY SUPPORT SERVICES › Section 317:30-5-412 - Description of services

Current through Vol. 41, No. 20, July 1, 2024
Family support services include services identified in (1)
					 through (6) of this section. Providers of any family support service must have
					 an applicable SoonerCare Provider Agreement for Home and Community-Based
					 Services (HCBS) Waiver Providers for persons with developmental
					 disabilities.
(1)
Transportation
				  services.
Transportation services are provided per Oklahoma
				  Administrative Code (OAC)
				  317:40-5-103.
(2)
Assistive technology (AT) devices
				  and services.
AT devices and services are provided per OAC
				  317:40-5-100.
(3)
Architectural modification.
Architectural modification services are provided per OAC
				  317:40-5-101.
(4)
Family training.
(A)
Minimum qualifications.
(i) Individual providers must have a
				  Developmental Disabilities Services (DDS) Family Training application and
				  training curriculum approved by DDS staff. Individual providers must holda
				  current licensure, certification, or a bachelor's degree in a human service
				  field related to the approved training curriculum, or other bachelor's degree
				  combined with a minimum of five 5 years' experience in the intellectual
				  disabilities field. Only individuals named on the SoonerCare Provider Agreement
				  to provide Family Training services may provide service to members.
(ii) Agency or business providers must have a
				  (DDS) Family Training application and training curriculum approved by DDS
				  staff. Agency or business provider training staff must hold a current
				  licensure, certification, or a bachelor's degree in a human service field
				  related to the approved training curriculum or other bachelor's degree combined
				  with a minimum of five (5) years experience in the intellectual disabilities
				  field. The credentials of new training staff hired by an approved DDS HCBS
				  Family Training agency or business provider must be submitted to and approved
				  by the DDS programs manager for Family Training prior to new staff training
				  members or members' families.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 41 - FAMILY SUPPORT SERVICES › Section 317:30-5-413 - Diagnosis codes [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95
						(emergency) ; Added at 12 Ok Reg 3131, eff 7-27-95 ; Revoked at 30 Ok Reg 1169,
						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 43 - AGENCY COMPANION, SPECIALIZED FOSTER CARE, DAILY LIVING SUPPORTS, GROUP HOMES, AND COMMUNITY TRANSITION SERVICES › Section 317:30-5-420 - Home and Community-Based Services Waivers for persons with an intellectual disability or certain persons with related conditions

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Health Care Authority (OHCA) administers Home
					 and Community-Based Services (HCBS) Waivers for persons with an intellectual
					 disability and certain persons with related conditions that are operated by the
					 Oklahoma Department of Human Services Developmental Disabilities Services
					 Division (DDSD). The Community Waiver and Homeward Bound Waiver allow payment
					 for residential supports as defined in the waiver approved by the Centers for
					 Medicare and Medicaid Services (CMS).
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 25 Ok Reg 124, eff 10-1-07 (emergency); Amended at 25 Ok
					 Reg 1192, eff 5-25-08; Amended at 29 Ok Reg 1076, 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 43 - AGENCY COMPANION, SPECIALIZED FOSTER CARE, DAILY LIVING SUPPORTS, GROUP HOMES, AND COMMUNITY TRANSITION SERVICES › Section 317:30-5-421 - Coverage

Current through Vol. 41, No. 20, July 1, 2024
Residential supports must be included in the member's
					 Individual Plan (IP). Arrangements for care under this program must be made
					 through the member's case manager.
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 25 Ok Reg 124, eff 10-1-07 (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 43 - AGENCY COMPANION, SPECIALIZED FOSTER CARE, DAILY LIVING SUPPORTS, GROUP HOMES, AND COMMUNITY TRANSITION SERVICES › Section 317:30-5-422 - Description of services

Current through Vol. 41, No. 20, July 1, 2024
Residential supports include:
(1) agency companion services (ACS) per
				  Oklahoma Administrative Code (OAC)317:40-5;
(2) specialized foster care (SFC) per OAC
				  317:40-5;
(3) daily living supports
				  (DLS):
(A) Community Waiver per OAC
				  317:40-5-150;
				  and
(B) Homeward Bound Waiver per
				  OAC
				  317:40-5-153;
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 43 - AGENCY COMPANION, SPECIALIZED FOSTER CARE, DAILY LIVING SUPPORTS, GROUP HOMES, AND COMMUNITY TRANSITION SERVICES › Section 317:30-5-423 - Coverage limitations

Current through Vol. 41, No. 20, July 1, 2024
(a) Coverage
				  limitations for residential supports for members with an intellectual
				  disability are:
(1) Description: agency
				  companion services (ACS); Unit: one day; Limitation: 366 units per
				  year;
(2) Description: specialized
				  foster care (SFC); Unit: one day; Limitation: 366 units per year;
(3) Description: daily living supports (DLS);
				  Unit: one day; Limitation: 366 units per year; and
(4) Description: group home services; Unit:
				  one day; Limitation: 366 units per year.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 43 - AGENCY COMPANION, SPECIALIZED FOSTER CARE, DAILY LIVING SUPPORTS, GROUP HOMES, AND COMMUNITY TRANSITION SERVICES › Section 317:30-5-424 - Diagnosis code [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 25 Ok Reg 124,
						eff 10-1-07 (emergency) ; Amended at 25 Ok Reg 1192, eff 5-25-08 ; Revoked at
						30 Ok Reg 1169, 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 45 - OPTOMETRISTS › Section 317:30-5-430 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Payment can be made to a licensed optometrist who has a
					 current contract on file with the Oklahoma Health Care Authority (OHCA) for
					 services within the scope of Optometric practice as defined by controlling
					 State law; provided, however, that services performed by out-of-state providers
					 shall only be compensable to the extent that they are covered services.
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 3354, eff 8-1-00 (emergency); Amended 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 45 - OPTOMETRISTS › Section 317:30-5-431 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
Payment is made to optometrists as set forth in this
					 Section.
(1)
Adults.
Payment can be made for medical services that are reasonable and necessary for
				  the diagnosis and treatment of illness or injury up to the patient's maximum
				  number of allowed office visits per month.
(A)
				  There is no provision for routine eye exams, examinations for the purpose of
				  prescribing glasses or visual aids, determination of refractive state,
				  treatment of refractive errors, or purchase of lenses, frames, or visual aids.
				  Payment is made for treatment of medical or surgical conditions which affect
				  the eyes. Prior to providing non-covered services, providers must notify
				  members in writing of those services not covered by SoonerCare. Determination
				  of refractive state or other non-covered services may be billed to the patient
				  if properly notified.
(B) The
				  global surgery fee allowance includes preoperative evaluation and management
				  services rendered the day before or the day of surgery, the surgical procedure,
				  and routine postoperative period. Co-management for cataract surgery is filed
				  using appropriate CPT codes, modifiers and guidelines. If an optometrist has
				  agreed to provide postoperative care, the surgeon's information must be in the
				  referring provider's section of the claim.
(C) Payment for laser surgery to optometrist
				  is limited to those optometrists certified by the Board of Optometry as
				  eligible to perform laser surgery.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 45 - OPTOMETRISTS › Section 317:30-5-432 - Procedure Codes

Current through Vol. 41, No. 20, July 1, 2024
(a) The appropriate
				  procedure codes used for billing eye care services are found in the Current
				  Procedural Terminology (CPT) and HCPCS Coding Manuals.
(b) Vision screening is a component of all
				  eye exams performed by ophthalmologists or optometrists and is not billed
				  separately.
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 3354, 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 25 Ok
					 Reg 653, eff 2-1-08 through 7-14-08 (emergency)1;
					 Amended at 25 Ok Reg 2634, eff 7-25-08
1This emergency action expired
					 on 7-14-08 before being superseded by a permanent action. Upon expiration of an
					 emergency amendatory action, the last effective permanent text is reinstated.
					 Therefore, on 7-15-08 (after the 7-14-08 expiration of the emergency action),
					 the text of 317:30-5-432 reverted back to the permanent text that became
					 effective 6-27-02, as was last published in the 2006 Edition of the OAC, and
					 remained as such until amended again by permanent action on
					 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 45 - OPTOMETRISTS › Section 317:30-5-432.1 - Corrective lenses and optical supplies

Current through Vol. 41, No. 20, July 1, 2024
(a) When medically necessary, payment will be
				  made for lenses, frames, low vision aids and certain tints for children.
				  Coverage includes lenses and frames to protect children with monocular vision.
				  Coverage includes two sets of non-high-index polycarbonate lenses and frames
				  per year. Any lenses and frames beyond this limit must be prior authorized and
				  determined to be medically necessary. All non-high-index lenses must be
				  polycarbonate.
(b) Corrective
				  lenses must be based on medical need. Medical need includes a significant
				  change in prescription or replacement due to normal lens wear.
(c) SoonerCare provides frames when medically
				  necessary. Frames are expected to last at least one year and must be reusable.
				  If a lens prescription changes, the same frame must be used if possible.
(d) Providers must accept
				  SoonerCare reimbursement as payment in full for services rendered, except when
				  authorized by SoonerCare (e.g., copayments, other cost sharing arrangements
				  authorized by the State).
(1) Providers must
				  be able to dispense standard lenses and frames which SoonerCare would fully
				  reimburse with no cost to the eligible member.
(2) If the member wishes to select lenses and
				  frames with special features which exceed the SoonerCare allowable fee, and are
				  not medically necessary, the member may be billed the excess cost. The provider
				  must obtain signed consent from the member acknowledging that they are
				  selecting lenses and/or frames that will not be covered in full by SoonerCare
				  and that they will be responsible to pay the excess cost. The signed consent
				  must be included in the member's medical record.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 45 - OPTOMETRISTS › Section 317:30-5-433 - Diagnosis codes [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Revoked at 17 Ok Reg 3354, 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 47 - OPTICAL SUPPLIERS › Section 317:30-5-450 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Payment can be made to optical suppliers who have a
					 current SoonerCare contract with the OHCA.
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