Okla. Admin. Code § 317:25-7-2 - Sooner Care Choice: overview
(a) The
Oklahoma Health Care Authority (OHCA) operates a Primary Care Case Management
(PCCM) system for SoonerCare Choice eligible members. PCCM is a managed care
model in which each enrollee has a medical home with a primary care provider
(PCP). Enrollees may select their own primary care provider or clinic as their
PCP if that provider is enrolled with OHCA as a PCP and as a SoonerCare
provider. Those who do not choose a PCP, may be assigned to one(1). Members may
change PCPs at any time.
(b) The
PCP is paid a monthly care coordination payment in accordance with the
conditions in the PCP's SoonerCare Choice contract to provide or otherwise
assure the delivery of medically-necessary preventive and primary care medical
services, including securing referrals for specialty services and prior
authorizations for an enrolled group of eligible members, with the exception of
services described in subsection (c) of this Section for which authorization is
not required. The PCP assists the member in gaining access to the health care
system and monitors the member's condition, health care needs and service
delivery.
(c) Services which do
not require a referral from a PCP include preventive or primary care services
rendered by another SoonerCare contracted provider such as: outpatient
behavioral health services; vision services for children; dental services;
child abuse/sexual abuse examinations; prenatal and obstetrical services;
family planning services; emergency physician and hospital services; chronic
disease prevention and management programs and other care coordination
programs; and services delivered to Native Americans at Indian Health Service,
tribal, or urban Indian clinics. Female members may access a SoonerCare women's
health specialist without a referral for covered routine and preventive health
care services. This is in addition to the enrollee's PCP if that source is not
a woman's health specialist.
(d)
SoonerCare Choice covered services delivered by a PCP are reimbursed at the
SoonerCare fee schedule rate under the procedure code established for each
individual service. If services are provided or authorized by a PCP, the OHCA
does not make SoonerCare Choice payments for services delivered outside the
scope of coverage of the SoonerCare Choice program; thus, a referral by a PCP
does not guarantee payment.
(e) A
PCP may charge a co-payment for services provided to SoonerCare members in
accordance with Oklahoma Administrative Code (OAC)
317:30-3-5(d).
(f) Members with chronic
conditions may elect to enroll in a health management program to improve their
health.
(g) PCPs may elect to
participate in Health Access Networks pursuant to Subchapter 9 to improve
access to care.
(h) PCPs may elect
to participate in a Health Management Program pursuant to Subchapter 11 to
improve access to care.
Notes
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