Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-1 - Creation and implementation of rules; applicability

Current through Vol. 41, No. 20, July 1, 2024
(a) Medical rules of the Oklahoma Health Care
				  Authority (OHCA) are set by the OHCA Board. The rules are based upon the
				  recommendations of the Chief Executive Officer of the Authority, the Deputy
				  State Medicaid Director, the State Medicaid Director, OHCA Tribal partners and
				  the OHCA Medical Advisory Committee. The State Medicaid Director is responsible
				  for implementing medical policies and programs and directing the Fiscal Agent
				  regarding proper payment of claims.
(b) Payment to practitioners under Medicaid
				  is made for services clearly identifiable as personally rendered services
				  performed on behalf of a specific member. There are no exceptions to personally
				  rendered services unless specifically set out in coverage guidelines.
(c) Payment is made on behalf of Medicaid
				  eligible individuals for services within the scope of the Authority medical
				  programs. Services cannot be paid under Medicaid for ineligible individuals or
				  for services not covered under the scope of medical programs or that do not
				  meet documentation requirements. These claims will be denied, or in some
				  instances upon post-payment review, payment will be recouped.
(d) Payment to practitioners on behalf of
				  Medicaid eligible individuals is made only for services that are medically
				  necessary and essential to the diagnosis and treatment of the patient's
				  presenting problem. Wellness examinations and diagnostic testing are not
				  covered for adults unless specifically set out in coverage
				  guidelines.
(e) The scope of the
				  medical program for eligible children is the same as for adults except as
				  further set out under Early and Periodic Screening, Diagnostic and Treatment
				  (EPSDT) service guidelines.
(f)
				  Services, provided within the scope of the Oklahoma Medicaid program, shall
				  meet medical necessity criteria. Requests by qualified providers for services
				  in and of itself shall not constitute medical necessity. The OHCA shall serve
				  as the final authority pertaining to all determinations of medical necessity.
				  Some service limits listed within OAC 317:30 can be exceeded for expansion
				  adults, upon meeting medical necessity as determined by OHCA and in alignment
				  with the Oklahoma Medicaid State Plan. Physical therapy, occupational therapy
				  and speech language pathology have hard limits, which are set at forty-five
				  (45) visits for both habilitation and rehabilitation - a cumulative total of 90
				  visits [fifteen (15) visits of each therapy]. Members must meet medical
				  necessity criteria, prior authorization, and all other documentation
				  requirements. Medical necessity is established through consideration of the
				  following standards:
(1) Services must be
				  medical in nature and must be consistent with accepted health care practice
				  standards and guidelines for the prevention, diagnosis or treatment of symptoms
				  of illness, disease or disability;
(2) Documentation submitted in order to
				  request services or substantiate previously provided services must demonstrate
				  through adequate objective medical records and other supporting records,
				  evidence sufficient to justify the member's need for the service;
(3) Treatment of the member's condition,
				  disease or injury must be based on reasonable and predictable health
				  outcomes;
(4) Services must be
				  necessary to alleviate a medical condition and must be required for reasons
				  other than convenience for the member, family, or medical provider;
(5) Services must be delivered in the most
				  cost-effective manner and most appropriate setting; and
(6) Services must be appropriate for the
				  member's age and health status and developed for the member to achieve,
				  maintain, or promote functional capacity.