Okla. Admin. Code § 317:30-3-14 - Freedom of choice
(a)
Any
Qualified provider. The Oklahoma Health Care Authority (OHCA) assures
that any individual eligible for SoonerCare, may obtain services from any
institution, agency, pharmacy, person, or organization that is contracted with
OHCA and qualified to perform the services.
(b)
Member lock-in. SoonerCare
members who have demonstrated utilization above the statistical norm, during a
6-month period, may be "locked-in" to a prescriber and/or one pharmacy for
medications classified as controlled dangerous substances in accordance with
42 CFR
431.54.
(1)
Over-utilization patterns by SoonerCare members may be identified either by
referral or by OHCA automated computer systems. SoonerCare records, for a
6-month period, of those identified members are then reviewed. Medical and
pharmacy claim histories are reviewed by OHCA pharmacy consultants to determine
if the member has unreasonably utilized SoonerCare provider and/or prescription
services.
(2) If it is determined
that SoonerCare has been over-utilized, the member may be notified, by letter,
of the need to select a prescriber and/or pharmacy and of their opportunity for
a fair hearing in accordance with OAC
317:2-1-2. If the member
does not select a prescriber or pharmacy, one will be selected for the member.
(3) The prescriber and/or pharmacy
of choice, unless the aforementioned providers have been identified as having
problems with over-utilization, are notified by letter and given an opportunity
to accept or decline to be the member's prescriber and/or pharmacy.
(4) When the provider accepts, a confirmation
letter is sent to both member and provider showing the effective date of the
arrangement.
(5) After the lock-in
arrangement is made, the provider may file claims for services provided in
accordance with OHCA guidelines.
(6) Locked-in members may obtain emergency
services from an emergency room facility for an emergency medical condition or
as part of an inpatient admission.
(7) If a claim for a controlled dangerous
substance is filed by another pharmacy, the claim will be denied.
(8) A member placed in the lock-in program
will remain in lock-in status for a minimum of 24 months. While in lock-in
status, the member's usage shall be monitored periodically and shall be
reviewed at the end of 24 months.
(9) Following a review, OHCA may elect to
continue lock-in for an additional period of up to 24 months, remove the member
from lock-in based upon medical necessity, or remove the member based upon
program compliance. The member will be provided written notice of OHCA's
decision and afforded an opportunity to appeal. OHCA retains the right at any
time to impose sanctions in an appropriate case pursuant to OAC
317:35-13-7
or to take other appropriate action for abusive conduct.
(10) The member in the lock-in program may
make a request to change providers after the initial three months; when the
member moves to a different city or if the member feels irreconcilable
differences will prevent necessary medical care. Change of providers based on
irreconcilable differences must be approved by OHCA staff or contractor.
(11) OHCA may make a provider
change when the provider makes a request for change or may initiate a change
anytime it is determined necessary to meet program goals.
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.