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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-133.2 - Ancillary services

Current through Vol. 41, No. 20, July 1, 2024
(a) Ancillary
				  services are those items which are not considered routine services. Ancillary
				  services may be billed separately to the SoonerCare program, unless
				  reimbursement is available from Medicare or other insurance or benefit
				  programs. Coverage criteria, utilization controls and program limitations are
				  specified in Part 17 of OAC 317:30-5. Ancillary services are limited to the
				  following services:
(1) Services requiring
				  prior authorization:
(A) External breast
				  prosthesis and support accessories.
(B) Ventilators and supplies.
(C) Total Parenteral Nutrition (TPN), and
				  supplies.
(D) Custom seating for
				  wheelchairs.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-133.3 - Nursing home ventilator-dependent and tracheostomy care services

Current through Vol. 41, No. 20, July 1, 2024
(a) Admission is
				  limited to ventilator-dependent and/or qualified tracheostomy
				  residents.
(b) The
				  ventilator-dependent resident and/or qualified tracheostomy resident must meet
				  the current nursing facility level of care criteria. (Refer to OAC
				  317:30-5-123.)
(c) All criteria must be present in order for
				  a resident to be considered ventilator-dependent:
(1) The resident is not able to breathe
				  without a volume with a backup.
(2)
				  The resident must be medically dependent on a ventilator for life support 6
				  hours per day, seven days per week.
(3) The resident has a
				  tracheostomy.
(4) The resident
				  requires daily respiratory therapy intervention (i.e., oxygen therapy,
				  tracheostomy care, physiotherapy or deep suctioning). These services must be
				  available 24 hours a day.
(5) The
				  resident must be medically stable and not require acute care services. A
				  Registered Nurse or Licensed Practical Nurse must be readily available and have
				  primary responsibility of the unit at all times.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-134 - Nurse Aide Training Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) Nurse Aide training programs and
				  competency evaluation programs occur in two settings, a nursing facility
				  setting and private training courses. Private training includes, but is not
				  limited to, certified training offered at vocational technical institutions.
				  This rule outlines payment to qualified nurse aides trained in either
				  setting.
(b) In the case a nursing
				  facility provides training and competency evaluation in a program that is not
				  properly certified under federal law, the Oklahoma Health Care Authority may
				  offset the nursing facility's payment for monies paid to the facility for these
				  programs. Such action shall occur after notification to the facility of the
				  period of non-certification and the amount of the payment by the Oklahoma
				  Health Care Authority.
(c) In the
				  case of nurse aide training provided in private training courses, reimbursement
				  is made to nurse aides who have paid a reasonable fee for training in a
				  certified training program at the time training was received. The federal
				  regulations prescribe applicable rules regarding certification of the program
				  and certification occurs as a result of certification by the State Survey
				  Agency. For nurse aides to receive reimbursement for private training courses,
				  all of the following requirements must be met:
(1) the training and competency evaluation
				  program must be certified at the time the training occurred;
(2) the nurse aide has paid for
				  training;
(3) a reasonable fee was
				  paid for training (however, reimbursement will not exceed the maximum amount
				  set by the Oklahoma Health Care Authority of 800 dollars);
(4) the Oklahoma Health Care Authority is
				  billed by the nurse aide receiving the training within 12 months of the
				  completion of the training . Reimbursement requests outside the first 12 months
				  are not compensable;
(5) the nurse
				  aide has passed her or his competency evaluation; and
(6) the nurse aide is employed at a
				  SoonerCare contracted nursing facility as a nurse aide during all or part of
				  the year after completion of the training and competency evaluation.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-135 - Intermediate care facility for the mentally retarded (ICF/MR) service fee [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 12 Ok Reg 3644, eff 9-8-95 (emergency); Amended at 13 Ok
					 Reg 1645, eff 5-27-96; Revoked at 17 Ok Reg 3509, eff 9-1-00 (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 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-136 - Nursing Facility Supplemental Payment Program [Revoked]

Current through Vol. 41, No. 20, July 1, 2024
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-136.1 - Pay-for-Performance (PFP) program

Current through Vol. 41, No. 20, July 1, 2024
(a)
Purpose.
The PFP program was established through Oklahoma State
				  Statute, Title 56, Section
				  56-1011.5 as amended. PFP's
				  mission is to enhance the quality of life for target citizens by delivering
				  effective programs and facilitating partnerships with providers and the
				  community they serve. The program has a full commitment to the very best in
				  quality, service and value which will lead to measurably improved quality
				  outcomes, healthier lifestyles, greater satisfaction and confidence for our
				  members.
(b)
Eligible
				  providers.
Any Oklahoma long-term care nursing facility that is licensed
				  and certified by the Oklahoma State Department of Health (OSDH) as defined in
				  Oklahoma Administrative Code (OAC)
				  317:30-5-120.
(c)
Quality measure care
				  criteria.
To maintain status in the PFP program, each nursing facility
				  shall submit documentation as it relates to program metrics quarterly or upon
				  the request of the Oklahoma Health Care Authority (OHCA). The program metrics
				  can be found on the OHCA's PFP website or on PFP/Quality of Care (QOC) data
				  collection portal. If any quality metric, listed below, is substituted or
				  removed by Centers of Medicare and Medicaid Services (CMS), an alternative
				  quality metric may be chosen with the support of participating partners. For
				  the period beginning October 1, 2019 and until changed by amendment, qualifying
				  facilities participating in the PFP program have the potential to earn an
				  average of the five dollars ($5.00) quality incentive per Medicaid patient per
				  day. Facility(s) baseline is calculated annually and will remain the same for
				  the twelve (12) month period. Facility(s) will meet or exceed five-percent (5%)
				  relative improvement or the CMS' national average each quarter for the
				  following metrics:
(1) Decrease percent of
				  high risk/unstageable pressure ulcers for long-stay residents.
(2) Decrease percent of unnecessary weight
				  loss for long-stay residents.
(3)
				  Decrease percent of use of anti-psychotic medications for long-stay
				  residents.
(4) Decrease percent of
				  urinary tract infection for long-stay residents.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-136.2 - Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) Enhanced Payment Program

Current through Vol. 41, No. 20, July 1, 2024
(a)
Overview.
This program provides enhanced payment for private
				  ICFs/IID that provide vocational services or day program services or both. The
				  purpose of the enhanced payment is to offset the costs incurred by ICFs/IID in
				  the provision of vocational services or day program services or both. Residents
				  who qualify for the enhanced program cannot receive the same services or
				  reimbursement under another program.
(b)
Definitions.
The following
				  words and terms, when used in this Section, will have the following meaning,
				  unless the context clearly indicates otherwise:
(1)
"Day program services"
means
				  a life enrichment program that is conducted in a dedicated service location.
				  The organized scheduled programming will vary but must meet the specific
				  program qualifications for participation. Day services programs provide diverse
				  opportunities for residents to participate in the broader community based on
				  the resident's specific care plan.
(2)
"Direct costs"
means the
				  costs for activities or items associated with day services and/or vocational
				  services programs. These items include salaries and wages of activities staff,
				  day services and vocational staff, and job coaches.
(3)
"Other costs"
means overhead
				  costs attributable to the provision of day and vocational services. For
				  example, rent, utilities, etc., not already paid for by Medicaid.
(4)
"Quality Review Committee"
means a committee responsible for the oversight of monitoring and analyzing the
				  accessibility and appropriateness of services being delivered.
(5)
"Vocational services"
means
				  the provision of paid employment in a structured vocational training program
				  for residents outside of the resident's home. The type of work will vary but
				  each provider must meet the specific program qualifications for participation.
				  Vocational service programs provide pre-vocational services training, that
				  prepare the residents for employment in a structured educational program. These
				  programs will utilize either a certified job coach or a designated staff, to
				  assist a resident eighteen (18) years and older, in achieving gainful
				  employment. Other achievements may include, sheltered employment, ongoing
				  employment support, job skills training and/or workshop experience in the
				  community.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-137 - Bariatric surgery

Current through Vol. 41, No. 20, July 1, 2024
(a)
Bariatric
				  surgery.
Gastric bypass and other types of weight-loss surgery, known as
				  bariatric surgery, makes surgical changes to the stomach and digestive system,
				  limits food intake and nutrient absorption, which leads to weight
				  loss.
(b)
Eligible
				  providers.
Bariatric surgery providers must be:
(1) Certified by the American College of
				  Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality
				  Improvement Program (MBSAQIP) as a Comprehensive Bariatric Surgery Center; or
(2) Currently participating in a
				  comprehensive multidisciplinary bariatric surgery quality assurance program and
				  a clinical outcomes assessment review as a pathway to accreditation; and
(3) Completed a fellowship
				  training in bariatric surgery or be a fellow of the American Society of
				  Metabolic and Bariatric Surgery (ASMBS) or a MBSAQIP verified surgeon; and
(4) Contracted with the Oklahoma
				  Health Care Authority (OHCA); and
(5) Have a demonstrated record of quality
				  assurance.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 10 - BARIATRIC SURGERY › Section 317:30-5-137.1

Current through Vol. 41, No. 20, July 1, 2024
Added at 27 Ok Reg
					 450, eff 12-3-09 (emergency); Added at 27 Ok Reg 939, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 10 - BARIATRIC SURGERY › Section 317:30-5-137.2

Current through Vol. 41, No. 20, July 1, 2024
Added at 27 Ok Reg
					 450, eff 12-3-09 (emergency); Added at 27 Ok Reg 939, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 10 - BARIATRIC SURGERY › Section 317:30-5-138 - General coverage [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 141, eff 10-8-06 (emergency); Added at 24 Ok Reg 890, eff 5-11-07; Revoked at
					 27 Ok Reg 450, eff 12-3-09 (emergency); Revoked at 27 Ok Reg 939, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 10 - BARIATRIC SURGERY › Section 317:30-5-139 - Member requirements [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 141, eff 10-8-06 (emergency); Added at 24 Ok Reg 890, eff 5-11-07; Revoked at
					 27 Ok Reg 450, eff 12-3-09 (emergency); Revoked at 27 Ok Reg 939, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 10 - BARIATRIC SURGERY › Section 317:30-5-140 - Coverage for children

Current through Vol. 41, No. 20, July 1, 2024
Bariatric surgery services are currently allowed for
					 members aged fifteen (15) to sixty-five (65), per OAC
					 317:30-5-137(c)
					 (1). Exceptions may be granted for member's younger than fifteen (15) if they
					 are proven to be medically necessary and are prior authorized. State and
					 Federal Medicaid law, including, but not limited to, Oklahoma's
					 federally-approved State Medicaid Plan, require the State to make the
					 determination as to whether services are medically necessary and does not allow
					 for reimbursement 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 OAC
					 317:30-3-57.1.
Added at 24 Ok Reg
					 141, eff 10-8-06 (emergency); Added at 24 Ok Reg 890, 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 10 - BARIATRIC SURGERY › Section 317:30-5-141

Current through Vol. 41, No. 20, July 1, 2024
Added at 24 Ok Reg
					 141, eff 10-8-06 (emergency); Added at 24 Ok Reg 890, 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 11 - MATERNITY CLINIC SERVICES [Revoked] › Section 317:30-5-175 - Eligible providers [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 24 Ok Reg 2070, 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 11 - MATERNITY CLINIC SERVICES [Revoked] › Section 317:30-5-176 - Coverage by category [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 141, eff 10-14-98 (emergency); Amended at 16 Ok
					 Reg 1429, eff 5-27-99; Revoked at 24 Ok Reg 2070, 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 11 - MATERNITY CLINIC SERVICES [Revoked] › Section 317:30-5-177 - 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 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 11 - MATERNITY CLINIC SERVICES [Revoked] › Section 317:30-5-178 - Covered services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Revoked at 24 Ok Reg 2070, 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 11 - MATERNITY CLINIC SERVICES [Revoked] › Section 317:30-5-179 - Billing [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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180 - Purpose and general provisions

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Part is to establish guidelines for the
					 Oklahoma Prescription Drug Discount Program (OPDDP) under Title 59, O.S.,
					 Section
					 353.5
					 et seq. The Oklahoma Prescription Drug Discount Program (OPDDP) enables
					 Oklahomans without prescription drug coverage to purchase prescription drugs at
					 the lowest possible out-of-pocket cost through the OPDDP's pharmacy network.
					 The Oklahoma Health Care Authority (OHCA) contracts with a Pharmacy Benefit
					 Manager (PBM) to administer the program. The OPDDP does not purchase
					 drugs.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180.1 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Part, have
					 the following meaning, unless the context clearly indicates otherwise:
"Enrollment Fee"
means the amount charged per
					 individual to enroll in the OPDDP.
"Network"
means a group of individual retail
					 pharmacies that contract with the designated Pharmacy Benefit Manager to
					 participate in the OPDDP and honor the discount offered through this
					 program.
"Patient Assistance Programs (PAP)"
means a
					 program that some pharmaceutical companies use to offer medication assistance
					 to low-income individuals and families. These programs typically require a
					 doctor's consent and proof of financial status. They may also require the
					 individual applying for their program either have no health insurance, or no
					 prescription drug benefit through their health insurance. Each pharmaceutical
					 company has specific eligibility requirements and application information.
					 Neither OHCA nor the contracted PBM have any authority or responsibility for
					 the structure of these private programs.
"Pharmacy Benefit Manager (PBM)"
means the
					 company contracted by OHCA to manage pharmacy networks, formularies, drug
					 utilization reviews, pharmacotherapeutic outcomes, claims and/or other features
					 of a pharmacy benefit.
"Prescription Drug"
means a drug which can be
					 dispensed only upon prescription by a health care professional authorized by
					 his or her licensing authority and which is approved for safety and
					 effectiveness as a prescription drug under Section 505 or 507 of the Federal
					 Food, Drug and Cosmetic Act (52 Stat. 1040 (1938), 21 U.S.C.A., Section 301
					 ).
"Prescription Drug Coverage"
means a payment
					 or discount applied toward prescription drugs purchased by or for a consumer as
					 part of a health insurance benefit.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180.2 - Eligibility

Current through Vol. 41, No. 20, July 1, 2024
In order to be eligible for the OPDDP, an individual
					 must:
(1) be an Oklahoma
				  resident;
(2) apply with the
				  Pharmacy Benefit Manager (PBM);
(3)
				  not have insurance to cover all or part of prescriptions;
(4) pay an enrollment fee when income is
				  above 150% Federal Poverty Level (FPL); and
(5) provide verification of income to
				  determine enrollment fee, co-pay, and eligibility for the manufacturer's
				  PAP.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180.3 - Services

Current through Vol. 41, No. 20, July 1, 2024
(a) Services
				  provided through the OPDDP include a discount negotiated by the PBM for
				  prescription drugs. The member purchases these discounted drugs with their
				  OPDDP drug card at a Network pharmacy.
(b) The Patient Assistance Program (PAP)
				  Application Assistance service provides a point of contact and applications to
				  assist qualified members in applying for free or substantially reduced prices
				  on prescription drugs through the manufacturer's Patient Assistance
				  Programs.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180.4 - Fraud

Current through Vol. 41, No. 20, July 1, 2024
Applicants should be advised that the knowing
					 misrepresentation of income or other information constitutes fraud and could
					 lead to prosecution and recoupment of funds expended on their
					 behalf.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 12 - THE OKLAHOMA PRESCRIPTION DRUG DISCOUNT PROGRAM › Section 317:30-5-180.5 - Pharmacy Benefit Manager

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The Oklahoma Health Care Authority (OHCA) will designate a PBM utilizing a
				  competitive bidding process under state law.
(b) The designated PBM administers the OPDDP
				  subject to administrative rules regulating the program and contract
				  requirements placed upon the PBM.
(c) Per state law, all discounts must be
				  passed through 100% to the member. No portion of any negotiated discount,
				  rebate, or any other discount may be retained by the PBM to fund the OPDDP or
				  for any other use.
Added at 24 Ok Reg
					 303, eff 12-1-06 (emergency); Added at 24 Ok Reg 676, eff 2-1-07 (emergency);
					 Added at 24 Ok Reg 2082, 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 13 - HIGH RISK PREGNANT WOMEN CASE MANAGEMENT SERVICES [Revoked] › Section 317:30-5-185 - Eligible providers and services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Revoked at 24 Ok Reg 2070, 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 13 - HIGH RISK PREGNANT WOMEN CASE MANAGEMENT SERVICES [Revoked] › Section 317:30-5-186 - 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 24 Ok Reg 2070, 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 13 - HIGH RISK PREGNANT WOMEN CASE MANAGEMENT SERVICES [Revoked] › Section 317:30-5-187 - 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; Amended at 19 Ok Reg 2134, eff 6-27-02; Revoked at 24 Ok Reg 2070, 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 13 - HIGH RISK PREGNANT WOMEN CASE MANAGEMENT SERVICES [Revoked] › Section 317:30-5-188 - Documentation of records [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 24 Ok Reg 2070, 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 14 - TARGETED CASE MANAGEMENT SERVICES FOR FIRST TIME MOTHERS AND THEIR INFANTS/CHILDREN [Revoked] › Section 317:30-5-190 - Eligible providers and services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg
					 1892, eff 3-17-98 (emergency); Added at 16 Ok Reg 1709, eff 3-9-99 (emergency);
					 Added at 17 Ok Reg 1204, eff 5-11-00; Amended at 18 Ok Reg 2569, eff 6-25-01;
					 Revoked at 24 Ok Reg 2070, 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 14 - TARGETED CASE MANAGEMENT SERVICES FOR FIRST TIME MOTHERS AND THEIR INFANTS/CHILDREN [Revoked] › Section 317:30-5-191 - Coverage [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg
					 1892, eff 3-17-98 (emergency); Added at 16 Ok Reg 1429, eff 5-27-99; Amended at
					 18 Ok Reg 2569, eff 6-25-01; Revoked at 24 Ok Reg 2070, 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 14 - TARGETED CASE MANAGEMENT SERVICES FOR FIRST TIME MOTHERS AND THEIR INFANTS/CHILDREN [Revoked] › Section 317:30-5-192 - Payment rates [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg
					 1892, eff 3-17-98 (emergency); Added at 16 Ok Reg 1429, eff 5-27-99; Amended at
					 18 Ok Reg 2569, eff 6-25-01; Amended at 19 Ok Reg 2134, eff 6-27-02; Revoked at
					 24 Ok Reg 2070, 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 14 - TARGETED CASE MANAGEMENT SERVICES FOR FIRST TIME MOTHERS AND THEIR INFANTS/CHILDREN [Revoked] › Section 317:30-5-193 - Documentation of records [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg
					 1892, eff 3-17-98 (emergency); Added at 16 Ok Reg 1429, eff 5-27-99; Revoked at
					 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-195 - General provisions [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 19 Ok Reg 2134, eff 6-27-02; Amended at 23 Ok Reg 2463, eff
					 6-25-06; Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-196 - Eligible providers [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 23 Ok Reg 2463, eff 6-25-06; Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-197 - Periodicity schedule [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 23 Ok Reg 2463, eff 6-25-06; Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-198 - Coverage by category [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 14 Ok Reg 524, eff 12-24-96 (emergency); Amended at 14 Ok
					 Reg 1785, eff 5-27-97; Amended at 16 Ok Reg 48, eff 9-11-98 (emergency);
					 Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 1927, eff 6-11-99;
					 Amended at 21 Ok Reg 2201, eff 6-25-04; Amended at 23 Ok Reg 2463, eff 6-25-06;
					 Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-199 - Periodic screening examination [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 23 Ok Reg 2463, eff 6-25-06; Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-200 - Interperiodic screening examination [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 19 Ok Reg 2134, eff 6-27-02; Revoked at 23 Ok Reg 2463, eff
					 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-201 - Reporting of suspected child abuse/neglect [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 23 Ok Reg 2463, eff 6-25-06; Revoked at 24 Ok Reg 2070, 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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-202 - Payment rates and billing [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 15 - CHILD HEALTH CENTERS [Revoked] › Section 317:30-5-203 - Billing [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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-204 - General information

Current through Vol. 41, No. 20, July 1, 2024
The emphasis of maternal and infant health licensed
					 clinical social work services is on providing psychosocial support, health and
					 behavior assessment and intervention focused on biopsycho-social factors
					 related to the member's perinatal health status. These services are intended
					 for women who are at risk due to drug/alcohol use, domestic violence, lack of
					 stable food/shelter, have high risk medical conditions, problems in the post
					 partum environment that interfere with the infant health and bonding and/or
					 other psychosocial concerns.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-205 - Eligible providers

Current through Vol. 41, No. 20, July 1, 2024
Eligible providers are Licensed Clinical Social Workers
					 (LCSWs) with a minimum of six hours of continuing education or technical
					 assistance in the area of Maternal and Infant Health. LCSWs must have a current
					 contract on file with the Oklahoma Health Care Authority and be licensed in the
					 state in which the service is being provided. Services may also be provided
					 through the Department of Health or other county health departments. Services
					 provided through the health departments must be provided by a LCSW. In the
					 event of a post-payment audit, LCSWs providing Maternal and Infant Health
					 Clinical Social Work services must be able to demonstrate that they have
					 completed at least six hours of continuing education or technical assistance
					 for each calendar year of providing care to SoonerCare members. The continuing
					 education or technical assistance must be in the area of Maternal and Infant
					 Health relevant to the provision of Social Work Services.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-206 - Coverage

Current through Vol. 41, No. 20, July 1, 2024
Maternal and infant health social work services are covered
					 for pregnant and postpartum women for whom a psychosocial condition exists that
					 may negatively impact the pregnancy and/or well being of the newborn infant.
					 SoonerCare members may self-refer or be referred by any provider.
					 Identification of the condition may be based on a CH-16 or the Licensed
					 Clinical Social Worker's initial assessment. Psychosocial assessment/counseling
					 is appropriate in order to develop a social work care plan based upon the
					 health risks due to psychosocial factors.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-207 - Limitations

Current through Vol. 41, No. 20, July 1, 2024
Coverage limitations for maternal and infant health social
					 work services are as follows:
(1)
				  Services are only covered when performed in the LCSWs' office setting,
				  patient's home or other confidential clinic setting.
(2) No separate reimbursement will be made to
				  a facility.
(3) Services billed by
				  a contracted LCSW must be provided face-to-face and in an individual
				  setting.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-208 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) Maternal and
				  infant health social work services must be billed using appropriate CPT codes
				  and guidelines.
(b) SoonerCare does
				  not allow more than thirty-two (32) units [fifteen (15) minutes = one (1) unit]
				  during the pregnancy which includes twelve (12) months postpartum.
(c) LCSWs that are employed by or remunerated
				  by another provider may not bill the SoonerCare program directly for services
				  if that billing would result in duplicate payment for the same
				  service.
(d) Only the LCSW directly
				  performing the care or a county health department may bill the SoonerCare
				  Program.
(e) The time indicated on
				  the claim form must be the time actually spent with the member.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 16 - MATERNAL AND INFANT HEALTH LICENSED CLINICAL SOCIAL WORKERS › Section 317:30-5-209 - Documentation

Current through Vol. 41, No. 20, July 1, 2024
All services must be reflected by documentation in the
					 patient records. All assessment and treatment services must include the
					 following:
(1) date;
(2) start and stop time for each timed
				  treatment session;
(3) signature of
				  the service provider;
(4)
				  credentials of service provider;
(5) documentation of the referral
				  source;
(6) problems(s), goals
				  and/or objectives identified on the treatment plan;
(7) methods used to address the problem(s),
				  goals and objectives;
(8) progress
				  made toward goals and objectives;
(9) patient response to the session or
				  intervention; and
(10) any new
				  problem(s), goals and/or objectives identified during the session.
Added at 25 Ok Reg
					 423, eff 11-1-07 (emergency); Added 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 17 - MEDICAL SUPPLIERS › Section 317:30-5-210.1 - Coverage for adults

Current through Vol. 41, No. 20, July 1, 2024
Coverage of medical supplies, equipment, and appliances for
					 adults complies with
					 42 Code of Federal Regulations (C.F.R.) §
											440.70 and is specified in Oklahoma
					 Administrative Code (OAC)
					 317:30-5-211.1
					 through OAC
					 317:30-5-211.19.
Added at 27 Ok Reg
					 453, eff 12-3-09 (emergency); Added at 27 Ok Reg 942, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-210.2 - Coverage for children

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage.
Medical supplies, equipment, and appliances are covered
				  for children.
(b)
Early and
				  Periodic Screening, Diagnostic and Treatment (EPSDT) Services.
EPSDT
				  services, supplies, or equipment that are determined to be medically necessary
				  for a child, and which are included within the categories of mandatory and
				  optional services in Section 1905(a) of Title XIX, are covered regardless of
				  whether such services, supplies, or equipment are listed as covered in the
				  Oklahoma Medicaid State Plan.
(c)
Medical necessity.
Federal regulations require the Oklahoma Health
				  Care Authority (OHCA) 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 that are considered
				  experimental. For more information regarding clinical trials, see Oklahoma
				  Administrative Code 317:30-3-57.1.
Added at 27 Ok Reg
					 453, eff 12-3-09 (emergency); Added at 27 Ok Reg 942, eff
					 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211 - Coverage for adults [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 13 Ok Reg 2321, eff 4-30-96 (emergency); Amended at 14 Ok
					 Reg 764, eff 11-25-96 (emergency); Amended at 14 Ok Reg 1780, eff 5-27-97;
					 Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 1204,
					 eff 5-11-00; Amended at 18 Ok Reg 477, eff 1-1-01 (emergency); Amended at 18 Ok
					 Reg 1130, eff 5-11-01; Amended at 24 Ok Reg 655, eff 2-1-07 (emergency);
					 Amended at 24 Ok Reg 2083, eff 6-25-07; Revoked at 24 Ok Reg 2890, eff 7-1-07
					 (emergency); Revoked at 25 Ok Reg 1161, eff
					 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.2 - Medical necessity

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage.
Coverage is subject to the requirement that the
				  equipment be necessary and reasonable for the treatment of an illness or
				  injury, or to improve the functioning of a malformed body member, in accordance
				  with state and federal Medicaid law, including, but not limited to, Oklahoma
				  Administrative Code (OAC)
				  317:30-3-1(f).
				  The member's diagnosis must warrant the type of equipment or supply being
				  purchased or rented.Items that are used for the following are not a benefit to
				  a member of any age:
(1) Routine personal
				  hygiene;
(2) Education;
(3) Exercise;
(4) Convenience, safety, or restraint of the
				  member, or his or her family or caregiver;
(5) Participation in sports; and/or
(6) Cosmetic purposes.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.3 - Prior authorization (PA)

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
PA is the electronic or written authorization issued by
				  the Oklahoma Health Care Authority (OHCA) to a provider prior to the provision
				  of a service. Providers should obtain a PA before providing services.
(b)
Requirements.
Billing must
				  follow correct coding guidelines as promulgated by the Centers for Medicare and
				  Medicaid Services (CMS) or per uniquely and publicly promulgated OHCA
				  guidelines. Medical supplies, equipment, and appliances claims must include the
				  most appropriate Healthcare Common Procedure Coding System (HCPCS) code as
				  assigned by the Medicare Pricing, Data, Analysis, and Coding (PDAC) or its
				  successor. Authorizations for services not properly coded will be denied. The
				  following services require PA:
(1) Services
				  that exceed quantity/frequency limits;
(2) Medical need for an item that is beyond
				  OHCA's standards of coverage;
(3)
				  Use of a Not Otherwise Classified (NOC) code or miscellaneous codes;
(4) Services for which a less costly
				  alternative may exist; and
(5)
				  Procedures indicating that a PA is required on the OHCA fee schedule.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.4 - Rental and/or purchase

Current through Vol. 41, No. 20, July 1, 2024
(a)
Purchase (New or Used).
Items may be purchased if they are
				  inexpensive accessories for other DME or the equipment itself will be used for
				  an extended period of time. The OHCA reserves the right to determine whether
				  items of DMEPOS will be rented or purchased.
(b)
Rental.
(1)
Continuous rental.
Items
				  that require regular and ongoing servicing/maintenance are rented for the
				  duration indicated by the physician's order and medical necessity. Examples
				  include, but are not limited to , oxygen and volume ventilators. The rental
				  payment includes routine servicing and all necessary repairs or replacements to
				  make the rented item functional.
(2)
Capped rental.
Items are
				  rented until the purchase price is reached. Capped rental items may be rented
				  for a maximum of 13 months. If the member changes suppliers during or after the
				  13th continuous month rental period, this does not result in a new rental
				  period. The supplier that provides the item to the member the 13th month of
				  rental is responsible for supplying the equipment, as well as routine
				  maintenance and servicing after the 13th month. If used equipment is issued to
				  the member, the usual and customary charge reported to the OHCA must accurately
				  reflect that the item is used.