Okla. Admin. Code § 317:25-7-7 - Referrals for specialty services
(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).
(e) Nothing in this section is intended to
absolve the PCP of their obligations in accordance with the conditions set
forth in their PCP SoonerCare Choice contract and the rules delineated in OAC
317:30.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.