Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 7 - Soonercare › Part 1 - GENERAL PROVISIONS › Section 317:25-7-7 - Referrals for specialty services

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  Primary care physicians (PCPs) are required to assure the delivery of medically
				  necessary preventive and primary care medical services, including securing
				  referrals for specialty services. Some services, as defined in Oklahoma
				  Administrative Code (OAC)
				  317:25-7-2(c)
				  and OAC
				  317:25-7-10(b),
				  do not require a referral from the PCP. A PCP referral does not guarantee
				  payment, as all services authorized by the PCP must be in the scope of coverage
				  of the SoonerCare Choice program to be considered compensable.
(b) Pursuant to OAC
				  317:30-3-1(f),
				  SoonerCare Choice referrals must always be made on the basis of medical
				  necessity. Referrals from the PCP are required prior to receiving the referred
				  service, except for retrospective referrals as deemed appropriate by the
				  PCP.
(c) The PCP and specialty
				  provider are responsible for maintaining appropriate documentation of each
				  referral to support the claims for medically necessary services.
(d) As approved and deemed appropriate, the
				  Oklahoma Health Care Authority (OHCA) may provide administrative referrals for
				  specialty services. Administrative referrals are only provided by the OHCA
				  under special and extenuating circumstances. Administrative referrals should
				  not be requested as a standard business practice. The OHCA will not process
				  retrospective administrative referrals, unless one(1) of the following
				  exceptions applies:
(1) The specialty
				  services are referred from an IHS, tribal, or urban Indian clinic;
(2) The specialty services are referred as
				  the result of an emergency room visit or emergency room follow-up visit;
				  or
(3) The retrospective
				  administrative referral request for specialty services is requested from the
				  OHCA within thirty (30) calendar days of the specialty care date of service.
(A) The referral is requested for
				  urgent/emergent care, including but not limited to, outpatient surgeries,
				  fracture care, and other procedures that require immediate attention.
(B) Annual, routine, and long-term follow up
				  appointments will not be considered for retrospective services. These type of
				  appointment referrals will need to be secured prior to the scheduling of the
				  appointment.
(C) If the
				  retrospective administrative referral is requested within the thirty (30)
				  calendar days, the request must include appropriate documentation for the OHCA
				  to approve the request. Appropriate documentation must include:
(i) Proof that the specialist has attempted
				  to collect a PCP referral from the member's assigned PCP. Documentation should
				  note who the requesting provider communicated with or a copy of the fax
				  verification that was sent to the PCP along with the denial reason;
				  and
(ii) Medical documentation to
				  substantiate that the specialty services are medically necessary pursuant to
				  OAC
				  317:30-3-1(f).