Okla. Admin. Code § 317:30-3-1 - Creation and implementation of rules; applicability
(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.
(g) Emergency medical condition means a
medical condition including injury manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected, by a reasonable and prudent
layperson, to result in placing the patient's health in serious jeopardy,
serious impairment to bodily function, or serious dysfunction of any bodily
organ or part.
(h) Verbal or
written interpretations of policy and procedure in singular instances is made
on a case-by-case basis and shall not be binding on this Agency or override its
policy of general applicability.
(i) The rules and policies in this Part apply
to all providers of service who participate in the program.
Notes
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