|317:30-3-1.||Creation and implementation of rules; applicability|
(a) Medical rules of the Oklahoma Health Care Authority (OHCA) are set by the Oklahoma Health Care Authority Board. The rules are based upon the recommendations of the Chief Executive Officer of the Authority, the Deputy Administrator for Health Policy, the Medicaid Operations State Medicaid Director, and the Advisory Committee on Medical Care for Public Assistance Recipients. The Medicaid Operations State Medicaid Director is responsible for implementing medical policies and programs and directing the Fiscal Agent with regard to 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 patient. 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. Well patient 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 EPSDT.
(f) Services provided within the scope of the Oklahoma Medicaid Program shall meet medical necessity criteria. Requests by medical services providers for services in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority shall serve as the final authority pertaining to all determinations of medical necessity. 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, evidence sufficient to justify the client's need for the service;
(3) Treatment of the client'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 client, 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 client's age and health status and developed for the client 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.
In order to be eligible for payment, providers must have on file with OHCA, an approved Provider Agreement. Through this agreement, the provider certifies all information submitted on claims is accurate and complete, assures that the State Agency's requirements are met and assures compliance with all applicable Federal and State regulations. These agreements are renewed at least every 5 years with each provider.
(1) The provider further assures compliance with Section 1352, Title 31 of the U.S. Code and implemented at 45 CFR Part 93 which provides that if payments pursuant to services provided under Medicaid are expected to exceed $100,000.00, the provider certifies federal funds have not been used nor will they be used to influence the making or continuation of the agreement to provide services under Medicaid. Upon request, the Authority will furnish a standard form to the provider for the purpose of reporting any non-federal funds used for influencing agreements.
(2) The provider assures in accordance with 31 USC 6101, Executive Order 12549, that they are not presently or have not in the last three years been debarred, suspended, proposed for debarment or declared ineligible by any Federal department or agency.
(3) For information regarding Provider Agreements or for problems related to a current agreement, contact the Oklahoma Health Care Authority, Provider Enrollment, P.O. Box 54015, Oklahoma City, Oklahoma 73154, or call 1-800-522-0114 option 5 toll free or 405-522-6205 for the Oklahoma City area.
|317:30-3-2.1.||Program Integrity Audits/Reviews|
(a) This section applies to all contractors/providers:
(1) "Contractor/provider" means any person or organization that has signed a provider agreement with the Oklahoma Health Care Authority (OHCA).
(2) "Extrapolation" means the methodology of estimating an unknown value by projecting, with a calculated precision (i.e., margin of error), the results of a probability sample to the universe from which the sample was drawn.
(3) "Probability sample" means the standard statistical methodology in which a sample is selected based on the theory of probability (a mathematical theory used to study the occurrence of random events).
(b) An OHCA audit/review includes the following:
(1) An examination of provider records, by either an on-site or desk audit. Claims may be examined for compliance with relevant federal and state laws and regulations, written provider billing instructions, numbered memoranda, and/or medical necessity.
(2) A draft audit/initial review report, which contains preliminary findings.
(3) An informal reconsideration period in which the provider may supply relevant information to clear any misunderstandings and/or findings.
(4) The right to a formal appeal, if the contractor/provider requests it.
(5) A final audit/review report.
(c) When OHCA conducts a probability sample audit, the sample claims are selected on the basis of recognized and generally accepted sampling methods. If audit reveals patterns of inappropriate coding, failure to adhere to SoonerCare policies, issues related to medical necessity, consistent patterns of overcharging, lack of appropriate documentation, or other fiscal abuse of the SoonerCare program, with an error rate of more than 10%, the provider may be required to reimburse OHCA the extrapolated amount.
(1) When projecting the overpayment, using statistical sampling, OHCA uses a sample that is sufficient to ensure a minimum 95% confidence level.
(2) When calculating the amount to be recovered, OHCA ensures that all overpayments and underpayments reflected in the probability sample are totaled and extrapolated to the universe from which the sample was drawn.
(3) OHCA does not consider non-billed services or supplies when calculating underpayments and overpayments.
(d) If sampling reveals an error rate of 10% or less, the provider will be required to reimburse OHCA for any overpayments noted during the review.
(e) In those instances when the probability sample results in an error rate in excess of 10%, the results of a probability sample may be used by OHCA to extrapolate the amount to be recovered.
(f) SoonerCare contracted providers shall have the option of requesting OHCA perform a full-scope audit or utilize an extrapolation method to determine overpayments, if during a review a statistical sample indicates an error rate greater than 10% of paid claims.
(1) The provider must select the overpayment determination method, full-scope audit or extrapolation, within the time constraints of the designated appeal.
(A) The additional labor cost to perform a full-scope audit will be carried by the OHCA if the review produces an error rate less than the initial error rate.
(B) The provider will be charged the cost of the full-scope audit if the review produces an error rate equal to or greater than the initial error rate.
(C) Cost will be determined through OHCA billable time plus all applicable overhead and/or the cost of contracted services.
(D) The provider must choose an independent contactor from an OHCA approved list of qualified contractors to perform the full-scope audit.
(2) The provider will be responsible for repayment of any identified overpayment resulting from the review method chosen.
(a) A group/corporation is a business entity under which one or more individual providers practice. A group does not require multiple professional providers. A single provider group is a valid group and would be identified by the business entity name. Providers who are in group affiliations and providers who are incorporated under a Federal Employer Identification Number (FEIN) may be paid as a group or corporation. Unless otherwise notified, payments will be issued to a provider as an independent provider, under the personal Social Security Number. To be paid as a group/corporation, or under the Federal Employer Identification Number, providers must contact OHCA to secure a contract for group/corporation billing. It will be the responsibility of the group/corporation to notify the OHCA of changes when a provider leaves or enters the group/corporation affiliation.
(b) A clinic is a facility or distinct part of a facility used for the diagnosis and treatment of outpatients. Clinics are limited to organizations serving specialized treatment requirements or distinct groups. Clinics are specific to specialized provider types as approved by the OHCA. Clinics must have a specialized current contract with the OHCA. Clinic services are covered under 317:30-5-575 through 317:30-5-578.
|317:30-3-3.1.||Medicaid Income Deferral Program|
(a) The Medicaid Income Deferral Program is a program that enables physician corporations, as defined in Title 59 of the Oklahoma Statutes, to voluntarily defer income that is paid to the corporation by the Single State Medicaid Agency.
(b) The voluntary income deferral by physician corporations (medical doctors, osteopathic physicians, dentists, surgeons, podiatrists, chiropractors, optometrists, and ophthalmologists) shall be subject to any federal provisions imposed by the Internal Revenue Code, Title 26 of the United States Code. The Health Care Authority may adopt a Plan which provides for the investment of deferral amounts in life insurance or annuity contracts which offer a choice of underlying investment options. The Plan shall provide that each physician corporation exercise those options independently from among choices offered by such contracts. Contract issuing companies shall be limited to companies which are licensed to do business in the state of Oklahoma.
(c) To be eligible for this program a physician corporation must have an existing contract with the Oklahoma Health Care Authority and the corporation must perform that contract for the term of the agreement. If a physician corporation fails to fulfill its service obligations under the contract, all deferral amount assets held for the benefit of that corporation shall be forfeited.
(d) No physician corporation shall be permitted to participate in the Plan without having prior independent tax and legal advice to do so.
|317:30-3-4.||Electronic fund transfer or direct deposit|
To comply with the Cash Management Act of 1990, the Medicaid agency and the Office of State Treasurer offer a service of Electronic Fund Transfer or Direct Deposit of Medicaid provider payments. These payments are deposited electronically by the State Treasurer to the provider's financial institution. Provider authorizations are mailed to new providers after initial enrollment in the Medicaid program. Additional Electronic Funds Transfer Authorization forms may be requested from Provider Relations.
|317:30-3-4.1.||Uniform Electronic Transaction Act|
The Oklahoma Health Care Authority enacts the provisions of the Uniform Electronic Transaction Act as provided in this Section with the exception to the act as provided in this Section.
(1) Scope of Act. The Electronic Transaction Act applies to an electronic record and an electronic signature created with a record that is generated, sent, communicated, received or stored by the Oklahoma Health Care Authority.
(2) Use of electronic records and electronic signatures. The rules regarding electronic records and electronic signatures apply when both parties agree to conduct business electronically. Nothing in these regulations requires parties to conduct business electronically. However, should a party have the capability and desire to conduct business electronically with the Oklahoma Health Care Authority, then the following guidelines must be adhered to:
(A) Only employees designated by the provider's agency may make entries in the member's medical record. All entries in the member's medical record must be dated and authenticated with a method established to identify the author. The identification method may include computer keys, Private/Public Key Infrastructure (PKIs), voice authentication systems that utilize a personal identification number (PIN) and voice authentication, or other codes. Providers must have a process in place to deactivate an employee's access to records upon termination of employment of the designated employee.
(B) When PKIs, computer key/code(s), voice authentication systems or other codes are used, a signed statement must be completed by the agency's employee documenting that the chosen method is under the sole control of the person using it and further demonstrate that:
(i) A list of PKIs, computer key/code(s), voice authentication systems or other codes can be verified;
(ii) All adequate safeguards are maintained to protect against improper or unauthorized use of PKIs, computer keys, or other codes for electronic signatures; and
(iii) Sanctions are in place for improper or unauthorized use of computer key/code(s), PKIs, voice authentication systems or other code types of electronic signatures.
(C) There must be a specific action by the author to indicate that the entry is verified and accurate. Systems requiring an authentication process include but are not limited to:
(i) Computerized systems that require the provider's employee to review the document on-line and indicate that it has been approved by entering a unique computer key/code capable of verification;
(ii) A system in which the provider's employee signs off against a list of entries that must be verified in the member's records;
(iii) A mail system that sends transcripts to the provider's employee for review;
(iv) A postcard identifying and verifying the accuracy of the record(s) signed and returned by the provider's employee; or
(v) A voice authentication system that clearly identifies author by a designated personal identification number or security code.
(D) Auto-authentication systems that authenticate a report prior to the transcription process do not meet the stated requirements and will not be an acceptable method for the authentication process.
(E) Records may be edited by designated administrators within the provider's facility but must be authenticated by the original author. Edits must be in the form of a correcting entry which preserves entries from the original record. Edits must be completed prior to claims submission or no later than 45 days after the date of service, whichever is later.
(F) Use of the electronic signature, for clinical documentation, shall be deemed to constitute a signature and will have the same effect as a written signature on the clinical documentation. The section of the electronic record documenting the service provided must be authenticated by the employee or individual who provided the described service.
(G) Any authentication method for electronic signatures must:
(i) be unique to the person using it;
(ii) identify the individual signing the document by name and title;
(iii) be capable of verification, assuring that the documentation cannot be altered after the signature has been affixed;
(iv) be under the sole control of the person using it;
(v) be linked to the data in such a manner that if the data is changed, the signature is invalidated; and
(vi) provide strong and substantial evidence that will make it difficult for the signer to claim that the electronic representation is not valid.
(H) Failure to properly maintain or authenticate medical records (i.e., signature and date entry) may result in the denial or recoupment of SoonerCare payments.
(3) Record retention for provider medical records. Providers must retain electronic medical records and have access to the records in accordance with guidelines found at OAC 317:30-3-15.
(4) Record retention for documents submitted to OHCA electronically.
(A) The Oklahoma Health Care Authority's system provides that receivers of electronic information may both print and store the electronic information they receive. The Oklahoma Health Care Authority is the custodian of the original electronic record and will retain that record in accordance with a disposition schedule as referenced by the Records Destruction Act. The Oklahoma Health Care Authority will retain an authoritative copy of the transferable record as described in the Electronic Transaction Act that is unique, identifiable and unalterable.
(i) Manner and format of electronic signature. The manner and format required by the Oklahoma Health Care Authority will vary dependant upon whether the sender of the document is a member or a provider. In the limited case where a provider is a client, the manner and format is dependent upon the function served by the receipt of the record. In the case the function served is a request for services, then the format required is that required by a recipient. In the case the function served is related to payment for services, then the format required is that required by a provider.
(ii) Recipient format requirements. The Oklahoma Health Care Authority will allow members to request SoonerCare services electronically. An electronic signature will be authenticated after a validation of the data on the form by another database or databases.
(iii) Provider format requirements. The Oklahoma Health Care Authority will permit providers to contract with the Oklahoma Health Care Authority, check and amend claims filed with the Oklahoma Health Care Authority, and file prior authorization requests with the Oklahoma Health Care Authority. Providers with a social security number or federal employer's identification number will be given a personal identification number (PIN). After using the PIN to access the database, a PIN will be required to transact business electronically.
(B) Providers with the assistance of the Oklahoma Health Care Authority will be required to produce and enforce a security policy that outlines who has access to their data and what transaction employees are permitted to complete as outlined in the policy rules for electronic records and electronic signatures contained in paragraph (2) of this section.
(C) Third Party billers for providers will be permitted to perform electronic transaction as stated in paragraph (2) only after the provider authorizes access to the provider's PIN and a power of attorney by the provider is executed.
(5) Time and place of sending and receipt. The provisions of the Electronic Transaction Act apply to the time and place of receipt with the exception of a power failure, Internet interruption or Internet virus. Should any of the exceptions in this paragraph occur, confirmation is required by the receiving party.
(6) Illegal representations of electronic transaction. Any person who fraudulently represents facts in an electronic transaction, acts without authority, or exceeds their authority to perform an electronic transaction may be prosecuted under all applicable criminal and civil laws.
|317:30-3-5.||Assignment and Cost Sharing|
(a) Definitions. The following words and terms, when used in subsection (c) of this Section, shall have the following meaning, unless the context clearly indicates otherwise:
(1) "Fee-for-service contract" means the provider agreement specified in OAC 317:30-3-2. This contract is the contract between the Oklahoma Health Care Authority and medical providers which provides for a fee with a specified service involved.
(2) "Within the scope of services" means the set of covered services defined at OAC 317:25-7 and the provisions of the SoonerCare Choice contracts in the SoonerCare Program.
(3) "Outside of the scope of the services" means all medical benefits outside the set of services defined at OAC 317:25-7 and the provisions of the SoonerCare Choice contracts in the SoonerCare Program.
(b) Assignment in fee-for-service. The OHCA's Medicaid State Plan provides that participation in the medical program is limited to providers who accept, as payment in full, the amounts paid by OHCA plus any deductible, coinsurance, or co-payment required by the State Plan to be paid by the member and make no additional charges to the member or others.
(1) OHCA presumes acceptance of assignment upon receipt of an assigned claim. This assignment, once made, cannot be rescinded, in whole or in part by one party, without the consent of the other party.
(2) Once an assigned claim has been filed, the member must not be billed and the member is not responsible for any balance except the amount indicated by OHCA. The only amount a member may be responsible for is a co-payment, or the member may be responsible for services not covered under the medical programs. In any event, the member should not be billed for charges on an assigned claim until the claim has been adjudicated or other notice of action received by the provider. Any questions regarding amounts paid should be directed to OHCA, Provider Services.
(3) When potential assignment violations are detected, the OHCA will contact the provider to assure that all provisions of the assignment agreement are understood. When there are repeated or uncorrected violations of the assignment agreement, the OHCA is required to suspend further payment to the provider.
(c) Assignment in SoonerCare. Any provider who holds a fee for service contract and also executes a contract with a provider in the SoonerCare Choice program must adhere to the rules of this subsection regarding assignment.
(1) If the service provided to the member is outside of the scope of the services outlined in the SoonerCare Contract, then the provider may bill or seek collection from the member.
(2) In the event there is a disagreement whether the services are in or out of the scope of the contracts referenced in (1) of this subsection, the Oklahoma Health Care Authority shall be the final authority for this decision.
(3) Violation of this provision shall be grounds for a contract termination in the fee-for-service and SoonerCare programs.
(d) Cost Sharing-Copayment. Section 1902(a)(14) of the Social Security Act permits states to require certain members to share some of the costs of SoonerCare by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. OHCA requires a co-payment of some SoonerCare members for certain medical services provided through the fee for service program. A co-payment is a charge which must be paid by the member to the service provider when the service is covered by SoonerCare. Section 1916(e) of the Act requires that a provider participating in the SoonerCare program may not deny care or services to an eligible individual based on such individual's inability to pay the co-payment. A person's assertion of their inability to pay the co-payment establishes this inability. This rule does not change the fact that a member is liable for these charges and it does not preclude the provider from attempting to collect the co-payment.
(1) Co-payment is not required of the following members:
(A) Individuals under age 21. Each member's date of birth is available on the REVS system or through a commercial swipe card system.
(B) Members in nursing facilities and intermediate care facilities for the mentally retarded.
(C) Home and Community Based Service waiver members except for prescription drugs.
(D) Native Americans providing documentation of ethnicity in accordance with 317:35-5-25 who receive items and services furnished by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services.
(2) Co-payment is not required for the following services:
(A) Family planning services. Includes all contraceptives and services rendered.
(B) Emergency services provided in a hospital, clinic, office, or other facility.
(C) Services furnished to pregnant women, if those services relate to the pregnancy or to any other medical condition which may complicate the pregnancy.
(3) Co-payments are required in an amount not to exceed the federal allowable for the following:
(A) Inpatient hospital stays.
(B) Outpatient hospital visits.
(C) Ambulatory surgery visits including free-standing ambulatory surgery centers.
(D) Encounters with the following rendering providers:
(ii) Advanced Practice Nurses,
(iii) Physician Assistants,
(v) Home Health Agencies,
(vi) Certified Registered Nurse Anesthetists,
(vii) Anesthesiologist Assistants,
(viii) Durable Medical Equipment providers, and
(ix) Outpatient behavioral health providers.
(E) Prescription drugs.
(i) Zero for preferred generics.
(ii) $0.65 for prescriptions having a SoonerCare allowable payment of $0.00-$10.00.
(iii) $1.20 for prescriptions having a SoonerCare allowable payment of $10.01-$25.00.
(iv) $2.40 for prescriptions having a SoonerCare allowable payment of $25.01-$50.00.
(v) $3.50 for prescriptions having a SoonerCare allowable payment of $50.01 or more.
(F) Crossover claims. Dually eligible Medicare/SoonerCare members must make a co-payment in an amount that does not exceed the federal allowable per visit/encounter for all Part B covered services. This does not include dually eligible HCBS waiver members.
(4) Aggregate cost-sharing liabilities in a given calendar year may not exceed 5% of the member's gross annual income.
|317:30-3-5.1.||Usual and Customary fees|
(a) Providers are required to indicate their usual and customary charge when submitting claims to SoonerCare. The usual and customary charge is the provider's charge for providing the same service to persons not entitled to SoonerCare benefits. For providers using a sliding fee scale, the usual and customary charge is the one that best represents the most frequently charged amount by the individual provider for the service when provided to non-SoonerCare members. Providers that do not have an established usual and customary charge indicate an amount reasonably related to the provider's cost for providing the service.
(b) Providers may not charge SoonerCare a higher fee than they charge non-SoonerCare patients even if the SoonerCare allowable is greater than the provider's usual and customary fee. Unless otherwise permitted by SoonerCare reimbursement methodology, individual claim payments are limited to the lesser of their usual and customary charge or the SoonerCare allowable.
(c) Providers indicate their usual and customary charge without deducting the co-payment for services that require a member co-payment. When applicable, the co-payment is systematically deducted.
(d) Payment is made based on the amount of the claim submitted, up to the maximum allowable amount.
|317:30-3-6.||Utilization review for physician/hospital services|
The Surveillance and Utilization Review System (SURS) is used to help identify patterns of inappropriate care and services.
(1) Use of this system enables OHCA to develop a comprehensive profile of any aberrant pattern of practice and reveals suspected instances of fraud or abuse in the SoonerCare Program. Also, the Utilization Review program is a useful tool in detecting the existence of any potential defects in the level of care or service provided under the SoonerCare Program.
(2) OHCA contracts with a Quality Improvement Organization (QIO) to review the length of stay and appropriateness of hospital admissions. Unresolved patterns of non-compliance with medical criteria for admissions, outpatient procedures and length of stay will be referred to OHCA.
|317:30-3-7.||Care assurance validation support review for long term care [REVOKED]|
Any covered service performed by a medical provider must be billed only after the service has been provided. No service or procedure may be pre-billed.
|317:30-3-9.||Medical services provided to relatives [REVOKED]|
Under paragraph (i), Section 1305 exemptions, Article 13, Title 68, O.S. 1981, sales to the State of Oklahoma are exempt from sales tax applicable in the State of Oklahoma.
|317:30-3-11.||Timely filing limitation|
(a) According to federal regulations, claims must be received by the Fiscal Agent within one year from the date of service. Payment will not be made on claims when more than 12 months have elapsed between the date the service was provided and the date of receipt of the claim by the Fiscal Agent. Federal regulations provide no exceptions to this requirement. Because of this requirement, caution should be exercised to assure claims are filed timely in all cases where an application for assistance has been filed. The following procedure is recommended. If the service is approaching the one year time limit and a case number has not been assigned and an approval for medical assistance has not been received, or there is a case number but the medical assistance case has not been approved, or a provider contract has not been approved, file a claim. The claim will be denied, however, the denial is proof of timely filing.
(b) Claims may be submitted anytime during the month.
(c) To be eligible for payment under Medicaid, claims for coinsurance and/or deductible must meet the Medicare timely filing requirements. If a claim for payment under Medicare has been filed in a timely manner, the Fiscal Agent must receive a Medicaid claim relating to the same services within 90 days after the agency or the provider receives notice of the disposition of the Medicare claim.
|317:30-3-11.1.||Resolution of claim payment|
(a) After the submission of a claim from a provider which had been adjudicated by the Authority, a provider may resubmit the claim under the following rules.
(b) The provider must have submitted the claim initially under the timely filing requirements found at OAC 317:30-3-11.
(c) The provider's resubmission of the claim must be received by the Oklahoma Health Care Authority no later than 24 months from the date of service. The only exceptions to the 24 month resubmission claim deadline are the following:
(1) administrative agency corrective action or agency actions taken to resolve a dispute, or
(2) reversal of the eligibility determination, or
(3) investigation for fraud or abuse of the provider, or
(4) court order or hearing decision.
|317:30-3-12.||Credits and adjustments|
When an overpayment has occurred, the provider should immediately refund the Oklahoma Health Care Authority, by check, to the attention of the Finance Division, P.O. Box 18299, Oklahoma City, OK 73154. In refunding OHCA, be sure to clearly identify the account to which the money is to be applied. The MMIS system has the capability of automatic credits and debits. When an erroneous payment occurs, which results in an overpayment, an automatic recoupment will be made to the provider's account against monies owed to the provider. For more specific information, refer to the Oklahoma Medicaid Provider Billing Manual, Chapter 9: Paid Claim Adjustment Procedures.
(a) Effective December 1, 1991, the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) requires certain Medicaid providers (hospitals, nursing facilities, hospices, home health agencies and non-technical medical care) to:
(1) provide all adult Medicaid patients and residents with written information about their rights under Oklahoma law to make health care decisions, including the right to accept or refuse treatment and the right to execute advance directives;
(2) inform patients and residents about the provider's policy on implementing advance directives. The written information required by law must be given out by hospitals at the time of the individual's admission as an inpatient; by nursing facilities when the individual is admitted as a resident; by a home health agency or non-technical care provider in advance of an adult individual receiving care; and by hospices at the time of initial receipt of hospice care;
(3) document in the patient's medical record whether he/she has signed an advance directive;
(4) not discriminate against an individual based on whether he/she has executed an advance directive; and
(5) provide staff and community education on advance directives.
(b) Out-of-state providers must comply with their respective state laws regarding advance directives.
|317:30-3-14.||Freedom of choice|
(a) Any Qualified provider. The Medicaid Agency assures that any individual eligible for Medicaid, may obtain services from any institution, agency, pharmacy, person, or organization that is qualified to perform the services.
(b) Recipient lock-in. Medicaid recipients who have demonstrated Medicaid usage above the statistical norm, during a 12-month period, may be "locked-in" to one primary physician and/or one pharmacy in accordance with Federal Regulation 42 CFR 431.54.
(1) Over-utilization patterns by Medicaid recipients may be identified either by referral or by OHCA automated computer systems. Medicaid records, for a 12-month period, of those identified recipients are then reviewed. Medical histories are ordered and reviewed by OHCA medical consultants to determine if high usage is medically justified.
(2) If it is determined that Medicaid has been over-utilized, the recipient may be notified, by letter, of the need to select a primary physician and/or pharmacy and of their opportunity for a fair hearing. If they do not select a physician one is selected for them. The primary-care provider must be a general practice, family practice, OB_GYN, pediatrician or internal-medicine physician and currently be enrolled as a Medicaid provider. In some cases recipients may be sanctioned under OAC 317:35-13-7.
(3) The provider of choice, unless that provider has been identified as having problems with Medicaid over-utilization, is notified by letter and is given an opportunity to accept or decline to be the recipient's primary physician.
(4) When the provider accepts, a confirmation letter is sent to both recipient and provider showing the effective date of the arrangement. The recipient will be issued a monthly Medicaid identification card which will designate them as a participant in the lock-in program.
(5) After the lock-in arrangement is made, the provider may file claims for services provided in accordance with OHCA procedure.
(6) Locked-in recipients may obtain emergency services from an emergency room facility for an emergency medical condition or as part of an inpatient admission.
(7) Medicaid-compensable visits to a specialist are covered when referred by the primary-care physician. The primary-care physician must be shown as the referring physician on Item 17 of HCFA-1500 submitted by the specialist.
(8) If a claim is filed by another provider, it is reviewed to see if a referral was given or services were for an acute physical injury. Claims not meeting this criteria are denied and the recipient is responsible for charges.
(9) When a recipient is enrolled into the lock-in program, usage is monitored when necessary and reviewed every 24 months. A provider may send a written request for recipient review. If review indicates utilization patterns meet lock-in removal criteria, the recipient may be removed from lock-in at the discretion of OHCA staff.
(10) During a review, OHCA may elect to continue lock-in, remove the recipient from lock-in because of medical necessity, remove them because of decreased utilization, or impose sanctions under OAC 317:35-13-7.
(11) The recipient in the lock-in program may make a written request to change providers after the initial three months; when the recipient moves to a different city or if the recipient feels irreconcilable differences will prevent necessary medical care. Change of providers based on irreconcilable differences must be approved by OHCA staff.
(12) OHCA may make a provider change when the provider makes a written request for change or may initiate a change anytime it is determined necessary to meet program goals.
Federal regulations and rules promulgated by the Oklahoma Health Care Authority Board require that the provider retain, for a period of six years, any records necessary to disclose the extent of services the provider, wholly owned supplier, or subcontractor, furnishes to recipients and, upon request, furnish such records to the Secretary of the Department of Health and Human Services. Records in a provider's office must contain adequate documentation of services rendered. Documentation must include the provider's signature and credentials. The provider's signature must be handwritten or electronically submitted if the provider and the Oklahoma Health Care Authority have agreed to conduct transactions by electronic means pursuant to the Uniform Electronic Act. Electronic records and electronic signatures must be in accordance with guidelines found at OAC 317:30-3-4.1. Where reimbursement is based on units of time, it will be necessary that documentation be placed in the member's record as to the beginning and ending times for the service claimed. All records must be legible. Failure to maintain legible records may result in denial of payment or recoupment of payment for services provided when attempts to obtain transcription of illegible records is unsuccessful or the transcription of illegible records appears to misrepresent the services documented. The provider may, after one year from the date of service(s), microfilm or microfiche the records for the remaining five years, as long as the microfilm or microfiche is of a quality that assures that the records remain legible. Electronic records are acceptable as long as they have a secured signature. Provider (other than individual practitioner) agrees to disclose, upon request, information relating to ownership or control, business transactions and criminal offenses involving any program under Title V of the Child Health Act or Titles, XVIII, XIX, XX, or XXI of the Federal Social Security Act.
|317:30-3-16.||Release of medical records|
Providers must agree to furnish the medical information necessary for payment of a claim upon request by the Fiscal Agent or OHCA. A release of information for medical records is obtained at the time an application is made for medical assistance. The application specifically states: "For the purpose of determining whether any payment will be made in the behalf of the patient for any medical services, hereafter reported, I do hereby authorize the Authority, or any representative thereof, authorized for the purpose of determining compensability of claims in the patient's behalf, to inspect all hospital and medical records pertaining to such hospitalization or medical services; and I do further authorize the hospital, physician, or other medical provider to release and furnish to the Authority and its representatives, any information shown in such records".
The Oklahoma Health Care Authority has assured compliance with the regulations of the Department of Health and Human Services, Title 45, Code of Federal Regulations, Part 80 (which implements Public Law 88-352, Civil Rights Act of 1964, Section 601), Part 84 (which implements Public Law 93-112, Rehabilitation Act of 1973, Section 504), Part 90 (which implements Public Law 94-135, Age Discrimination Act of 1975, Section 301), Title 9 of the Education Amendments of 1972; and Executive Orders 11246 and 11375.
(1) These laws and regulations prohibit excluding from participation in, denying the benefits of, or subjecting to discrimination, under any program or activity receiving Federal Financial Assistance any person on the grounds of race, color, sex, national origin, and qualified person on the basis of handicap, or unless program-enabling legislation permits, on the basis of age. Under these requirements, payment cannot be made to vendors providing care and/or services under Federally-assisted programs conducted by the Authority unless such care and service is provided without discrimination on the grounds of race, color, sex, national origin or handicap or without distinction on the basis of age except as legislatively permitted or required.
(2) Written complaints of noncompliance with any of these laws should be made to the Chief Executive Officer of the Oklahoma Health Care Authority, 4545 N. Lincoln Blvd, Suite 124, Oklahoma City, Oklahoma 73105, or the Secretary of Health and Human Services, Washington, D.C., or both.
Section 1909 of the Social Security Act provides criminal penalties for providers or recipients who make false statements or representations or intentionally conceal facts in order to receive payments or benefits. These penalties apply to kickbacks, bribes or rebates to refer or induce purchase of Medicaid compensable services. The penalties also apply to individuals who knowingly and willfully charge for services to recipients an amount in excess of amounts established by the State.
(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.
(1) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also recognizes recipient practices that result in unnecessary cost to the Medicaid program.
(2) "Conviction" or "Convicted" means a judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending.
(3) "Exclusion" means items or services which will not be reimbursed under Medicaid because they were furnished by a specific provider who has defrauded or abused the Medicaid program.
(4) "Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.
(5) "Knowingly" means that a person, with respect to information:
(A) has actual knowledge of the information;
(B) acts in deliberate ignorance of the truth or falsity of the information; or
(C) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.
(6) "Medical Services Providers" means:
(A) "Practitioner" means a physician or other individual licensed under State law to practice his or her profession or a physician who meets all requirement for employment by the Federal Government as a physician and is employed by the Federal Government in an IHS facility or affiliated with a 638 Tribal facility.
(B) "Supplier" means an individual or entity, other than a provider or practitioner, who furnishes health care services under Medicaid or other medical services programs administered by the Oklahoma Health Care Authority.
(C) "Provider" means:
(i) A hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or a hospice that has in effect an agreement to participate in Medicaid, or any other medical services program administered by the Oklahoma Health Care Authority, or
(ii) a clinic, a rehabilitation agency, or a public health agency that has a similar agreement.
(D) "Laboratories" means any laboratory or place equipped for experimental study in science or for testing or analysis which has an agreement with the Oklahoma Health Care Authority to receive Medicaid monies.
(E) "Pharmacy" means any pharmacy or place where medicines are compounded or dispensed or any pharmacist who has an agreement with OHCA to receive Medicaid monies for the dispensing of drugs.
(F) "Any other provider" means any provider who has an agreement with OHCA to deliver health services, medicines, or medical services for the receipt of Medicaid monies.
(7) "OIG" means Office of Inspector General of the Department of Health and Human Services.
(8) "Sanctions" means any administrative decision by OHCA to suspend or exclude a medical service provider(s) from the Medicaid program or any other medical services program administered by the Oklahoma Health Care Authority.
(9) "Suspension" means items or services furnished by a specified provider will not be reimbursed under the Medicaid program.
(10) "Willfully" means proceeding from a conscious motion of the will; voluntary, intending the result which comes to pass; intentional.
(b) Basis for sanctions.
(1) The Oklahoma Health Care Authority may sanction a medical provider who has an agreement with OHCA for the following reasons:
(A) Knowingly or willfully made or caused to be made any false statement or misrepresentation of material fact in claiming, or use in determining the right to, payment under Medicaid; or
(B) Furnished or ordered services under Medicaid that are substantially in excess of the recipient's needs or that fail to meet professionally recognized standards for health care; or
(C) Submitted or caused to be submitted to the Medicaid program bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs. However, the agency must not impose an exclusion under this section if it finds the excess charges are justified by unusual circumstances or medical complications requiring additional time, effort, or expense in localities in which it is accepted medical practice to make an extra charge in such case.
(2) The agency may base its determination that services were excessive or of unacceptable quality on reports, including sanction reports, from any of the following sources:
(A) The PRO for the area served by the provider or the PRO contracted by OHCA;
(B) State or local licensing or certification authorities;
(C) Peer review committees of fiscal agents or contractors;
(D) State or local professional societies;
(E) Surveillance and Utilization Review Section Reports done by OHCA; or
(F) Other sources deemed appropriate by the Medicaid agency or the OIG.
(3) OHCA must suspend from the Medicaid program any medical services provider who has been suspended from participation in Medicare or Medicaid due to a conviction of a program related crime. This suspension must be at a minimum the same period as the Medicare suspension.
(4) OHCA must also suspend any convicted medical services provider who is not eligible to participate in Medicare or Medicaid whenever the OIG directs such action. Such suspension must be, at a minimum, the same period as the suspension by the OIG.
(c) Procedure for imposing sanctions. The procedure for imposing a sanction under this section and the due process accorded in this section is provided at OAC 317:2-1-5.
|317:30-3-19.1.||Revocation of enrollment and billing privileges in the Medicaid Program.|
OHCA and providers have the right to terminate or suspend contracts with each other. Remedies are provided in this Section that may be used by the agency in addition to a formal contract action against the provider. When the use of these remedies results in a contract action, appropriate due process protections will be afforded to the provider for that contract action. Subsections (1) through (10) are additional remedies under which OHCA may revoke a currently enrolled provider or supplier's SoonerCare billing privileges and any corresponding provider agreement or supplier agreement.
(1) Noncompliance. The provider or supplier is determined not to be in compliance with the enrollment requirements described in OAC 317:30-3-2, or in the enrollment application applicable for its provider or supplier type. All providers and suppliers are granted an opportunity to correct the deficient compliance requirement before a final determination to revoke billing privileges, except for those imposed under subsections (2), (3), (5), or (7) of this Section.
(A) OHCA may request additional documentation from the provider or supplier to determine compliance if adverse information is received or otherwise found concerning the provider or supplier.
(B) Requested additional documentation must be submitted within 60 calendar days of request.
(2) Providerorsupplierconduct. The provider or supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier is:
(A) Excluded from the Medicare, Medicaid, or any other Federal health care program, as defined in 42 CFR 1001.2; or
(B) Is debarred, suspended, or otherwise excluded from participating in any other Federal procurement or nonprocurement program or activity.
(3) Felonies. The provider, supplier, or any owner of the provider or supplier, within the 10 years preceding enrollment or revalidation of enrollment, was convicted of a Federal or State felony offense that OHCA has determined to be detrimental to the best interests of the program and its beneficiaries. Denials based on felony convictions are for a period to be determined by the OHCA, but not less than 10 years from the date of conviction if the individual has been convicted on one previous occasion for one or more offenses. Offenses include but are not limited to:
(A) Felony crimes against persons, such as murder, rape, assault, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions;
(B) Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions;
(C) Any felony that placed the Medicaid program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct; and
(D) Any felonies that would result in mandatory exclusion under 42 U.S.C. ' 1320a-7a of the Social Security Act.
(4) False or misleading information. The provider or supplier certified as "true" misleading or false information on the enrollment application to be enrolled or maintain enrollment in the SoonerCare program. Offenders may be subject to either fines or imprisonment, or both, in accordance with current law and regulations.
(5) On-site review. OHCA determines, upon on-site review, that the provider or supplier is no longer operational to furnish SoonerCare covered items or services, or is not meeting SoonerCare enrollment requirements under statute or regulation to supervise treatment of, or to provide SoonerCare covered items or services for, SoonerCare members.
(6) Provider and supplier screening requirements.
(A) A provider does not submit an application fee that meets the requirements set forth in 42 CFR 455.460.
(B) Either of the following occurs:
(i) OHCA is not able to deposit the full application amount.
(ii) The funds are not able to be credited to the State of Oklahoma.
(C) The provider or supplier lacks sufficient funds in the account at the banking institution whose name is imprinted on the check or other banking instrument to pay the application fee; or
(D) There is any other reason why OHCA is unable to deposit the application fee.
(7) Misuse of billing number. The provider or supplier knowingly sells to or allows another individual or entity to use its billing number. This does not include those providers or suppliers who enter into a valid reassignment of benefits as specified in 42 U.S.C. ' 1396a (a)(32) or a change of ownership as outlined in 42 CFR 455.104(c) (within 35 days of a change in ownership).
(8) Abuseofbillingprivileges.The provider or supplier submits a claim or claims for services that could not have been furnished to a specific individual on the date of service. These instances include but are not limited to situations where the beneficiary is deceased, the directing physician or beneficiary is not in the State or country when services were furnished, or when the equipment necessary for testing is not present where the testing is said to have occurred.
(9) Failure to report. The provider or supplier did not comply with the reporting requirements specified in the SoonerCare provider agreement or regulations.
(10) Failure to document or provide OHCA access to documentation.
(A) The provider or supplier did not comply with the documentation or OHCA access requirements specified in the SoonerCare Provider Agreement.
(B) A provider or supplier that meets the revocation criteria specified in (10)(A) of this subsection is subject to revocation for a period of not more than 1 year for each act of noncompliance.
|317:30-3-20.||Appeals procedures (excluding nursing homes and hospitals)|
OHCA has established administrative procedures whereby a medical provider may request a review of the decision of the amount paid or the non-payment of medical services provided an eligible recipient. If the medical provider does not agree with the original payment from the Fiscal Agent, he/she may submit a written explanation as to why the adjustment is being requested and what action is to be taken, a copy of the paid remittance statement and/or detailed explanation of the paid information and a copy of the original claim with the corrections to be made for consideration of additional payment. The claim should be filed in accordance with the instructions in the OAC 317:30-7 for the type of medical provider involved.
|317:30-3-20.1.||Pharmacy grievance procedures and processes [REVOKED]|
|317:30-3-21.||Appeals procedures for nursing facilities|
Appeal procedures for denial, failure to renew, or termination of a nursing facility agreement are described at OAC 317:2-1-8. The Oklahoma State Department of Health, by agreement, continues to be responsible for hearings for licensure and certification as the survey agency.
|317:30-3-22.||Hospital reimbursement rate appeals [REVOKED]|
If the QIO, upon their initial review determines the admission should be denied, a notice is issued to the facility and the attending physician advising them of the decision and advising them that a reconsideration request may be submitted in accordance with the Medicare time frame. Additional information submitted with the reconsideration request will be reviewed by the QIO who utilizes an independent physician advisor. If the denial decision is upheld through this reconsideration review of additional information, OHCA is informed. At that point OHCA sends a letter to the hospital and physician requesting a refund of the SoonerCare payment previously made on the denied admission. The member is not responsible for denied charges.
|317:30-3-24.||Third party resources|
As the Medicaid Agency, OHCA is the payer of last resort, with few exceptions. When other resources are available, those resources must first be utilized. Exceptions to this policy are those receiving medical treatment through Indian Health Services and those eligible for the Crime Victims Compensation Act. Guidance for third party liability under the Insure Oklahoma program is found in OAC 317:45, Insure Oklahoma.
(1) If a member has coverage by an absent parent's insurance program or any other policy holder, that insurance resource must be used prior to filing a SoonerCare claim. This includes Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and any other insuring arrangements that provide a member access to healthcare. Members must comply with all requirements of their primary insurance as well as SoonerCare requirements in order to take advantage of both coverages. For example, a member must comply with the network restrictions of both the primary and SoonerCare plans as well as prior authorization requirements. If the member does not comply with the requirements of the primary plan, he/she will be responsible for the charges incurred. Denials by private insurance companies because the member did not secure a preauthorization or use a participating provider is not a sufficient reason for SoonerCare to make payment. If the provider is aware of private insurance or liability, a claim must first be filed with that source. When private insurance information is known to the OHCA, the eligibility verification system will reflect that information. If payment is denied by the primary insurance, except as stated above, the provider must attach the Explanation of Benefits (EOB), stating the reason for the denial, to the claim submitted to the Fiscal Agent. When payment is received from another source, that payment amount must be reflected on the claim form.
(2) It is possible that other resources are available but are unknown to OHCA. Providers will routinely question SoonerCare members to determine whether any other resources are available. In some instances, coverage may not be obvious, for example, the member may be covered by a policy on which he/she is not the subscriber (e.g., a child whose absent parent maintains medical and hospital coverage).
(3) If the provider receives payment from another source after OHCA has made payment, it is necessary that the provider reimburse OHCA for the SoonerCare payment. The provider may retain the primary insurance payment, if any, that represents payment for services that are not covered services under SoonerCare. By accepting the OHCA's payment, the provider agrees to accept it as payment in full and, therefore, cannot retain any portion of other resource money as payment for reduced charges on covered services. Other than SoonerCare copayments, a provider cannot bill a member for any unpaid portion of the bill or for a claim that is not paid because of provider administrative error. If, after reimbursing OHCA and retaining a portion of the other payment in satisfaction of any non-covered services there is money remaining, it must be refunded to the member.
(4) If a member is covered by a private health insurance policy or plan, he/she is required to inform medical providers of the coverage, including:
(A) provision of applicable policy numbers;
(B) assignment payments to medical providers;
(C) provision of information to OHCA of any coverage changes; and
(D) release of money received from a health insurance plan to the provider if the provider has not already received payment or to the OHCA if the provider has already been paid by the OHCA.
(5) Members are responsible for notifying their providers of the intent to make application for SoonerCare coverage and of any retroactive eligibility determinations. Members may be responsible for any financial liability if they fail to notify the provider of the eligibility determinations and as a result, the provider is unable to secure payment from OHCA.
(6) Members must present evidence of SoonerCare and any other health insurance coverage to a medical provider each time services are requested. Members may be responsible for any financial liability if they fail to furnish the necessary information before the receipt of services and as a result, the provider is unable to secure payment from OHCA.
|317:30-3-25.||Crossovers (coinsurance and deductible)|
(a) Medicare Part B. Payment is made for Medicare deductible and coinsurance on behalf of eligible individuals.
(b) Medicare Part A. Payment is made for Medicare deductible and coinsurance on behalf of eligible individuals.
(c) Medicare Advantage Plans. Payment is made for Medicare HMO co-payments. For services offered by Medicare Advantage Plans that revert to traditional Medicare type benefits, payment is made for coinsurance and deductibles according to subsection (a) and (b) in this section.
|317:30-3-26.||Medicare Physician Payment Reform methodology [REVOKED]|
(a) Applicability and scope. The purpose of this Section is to implement telemedicine policy that improves access to health care services by enabling the provision of medical specialty care in rural areas to meet the needs of members and providers alike, while complying with all applicable federal and state statutes and regulations. Telemedicine services are not an expansion of SoonerCare covered services but an option for the delivery of certain covered services. SoonerCare views telemedicine no differently than an office visit or outpatient consultation. However, if there are technological difficulties in performing an objective through medical assessment or problems in member's understanding of telemedicine, hands-on-assessment and/or care must be provided for the member. Quality of health care must be maintained regardless of the mode of delivery. A telemedicine encounter must comply with the Health Information Portability and Accountability Act (HIPAA) and shall include an originating site, distant site, and certified or licensed attendant to present the member at the originating site to the rendering provider located at the distant site.
(b) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.
(1) "Certified or licensed health care professional" means an individual who has successfully completed a prescribed program of study in any variety of health fields and who has obtained an Oklahoma state license or certificate indicating his or her competence to practice in that field.
(2) "Distant site" means the site where the specialty physician/practitioner providing the professional service is located at the time the service is provided via audio/video telecommunications.
(3) "Interactive telecommunications" means multimedia communications equipment that includes, at a minimum, audio/video equipment permitting two-way, real-time or near real-time service or consultation between the member and the practitioner.
(4) "Originating site" means the location of the SoonerCare member at the time the service is being performed by a contracted provider via audio/video telecommunications.
(5) "Rural area" means a county with a population of less than 50,000 people.
(6) "Store and forward" means the asynchronous transmission of medical information to be reviewed at a later time. A camera or similar device records (stores) an image(s) that is then sent (forwarded) via telecommunications media to another location for later viewing. The sending of x-rays, computed tomography scans, or magnetic resonance images are common store and forward applications. The original image may be recorded and/or forwarded in digital or analog format and may include video "clips" such as ultrasound examinations, where the series of images that are sent may show full motion when reviewed at the receiving location.
(7) "Telehealth" means the use of telecommunication technologies for clinical care (telemedicine), patient teaching and home health, health professional education (distance learning), administrative and program planning, and other diverse aspects of a health care delivery system.
(8) "Telemedicine" means the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the real-time or near real-time and in the physical presence of the member.
(9) "Telemedicine network" means a network infrastructure, consisting of computer systems, software and communications equipment to support telemedicine services.
(c) Coverage. SoonerCare coverage for telemedicine technology is limited to consultations, office visits, individual psychotherapy, psychiatric diagnostic interview examinations and testing, behavioral health assessments, behavioral health service plan development, pharmacologic management, and services for medically high risk pregnancies.
(1) An interactive telecommunications system is required as a condition of coverage.
(2) Coverage for telemedicine services is limited to members in rural areas or geographic areas where there is a lack of medical specialty, psychiatric or behavioral health expertise locally. The coverage of all telemedicine services is at the discretion of OHCA.
(3) Office and outpatient visits that are conducted via telemedicine are counted toward the applicable benefit limits for these services.
(4) Authorized originating sites are:
(A) The office of a physician or practitioner;
(B) A hospital;
(C) A school;
(D) An outpatient behavioral health clinic;
(E) A critical access hospital;
(F) A rural health clinic (RHC);
(G) A federally qualified health center (FQHC); or
(H) An Indian Health Service facility, a Tribal health facility or an Urban Indian clinic (I/T/U).
(5) Authorized distant site specialty providers, excluding professionals under supervision, are contracted:
(B) Advanced Registered Nurse Practitioners;
(C) Physicians Assistants;
(D) Genetic Counselors;
(E) Licensed Behavioral Health Professionals;
(F) Dieticians; and
(G) I/T/U's with specialty service providers as listed in (A) through (F) above.
(d) Non-covered services. Non-covered services include, but are not limited to:
(2) Electronic mail message;
(4) Unencrypted, non-HIPAA complaint Internet-based communications;
(5) Video cell phone interactions;
(6) Outpatient surgical services;
(7) Home Health services;
(8) Well child checkups, and preventive visits;
(9) Laboratory services;
(10) Audiologist services;
(11) Care coordination services; and
(12) Physical, speech, or occupational therapy services.
(e) Store and forward technology. SoonerCare covers store and forward technology for applications in which, under conventional health care delivery, the medical service does not require face-to-face contact between the member and the provider. Examples include teleradiology, telepathology, fetal monitor strips, as well as physician interpretation of electrocardiogram and electroencephalogram readings that are transmitted electronically. SoonerCare does not consider these services telemedicine as defined by OHCA and will not reimburse an originating site fee for these services.
(f) Conditions. The following conditions apply to all services rendered via telemedicine.
(1) Interactive audio and video telecommunications must be used, permitting encrypted real-time communication between the distant site physician or practitioner and the SoonerCare member. The telecommunication service must be secure and adequate to protect the confidentiality and integrity of the telemedicine information transmitted. As a condition of payment the member must be physically present at the originating site and must participate in the telemedicine visit. The originating site must provide pertinent medical information and/or records to the distant site provider via a secure HIPAA compliant transmission.
(2) Only telemedicine services provided utilizing an OHCA approved network are eligible for reimbursement.
(3) For SoonerCare reimbursement, telemedicine connections to rural areas must be located within Oklahoma and the health providers must be licensed in Oklahoma or practice at an I/T/U.
(4) The telemedicine equipment and transmission speed and image must be technically sufficient to support the service billed. If a peripheral diagnostic scope is required to assess the member, it must provide adequate resolution or audio quality for decision making. Staff involved in the telemedicine visit need to be trained in the use of the telemedicine equipment and competent in its operation.
(5) The medical or behavioral health related service must be provided by a distant site provider that is located at an approved HIPAA compliant site, or site in compliance with HIPAA Security Standards. A telemedicine approved site is one that has the proper security measures in place, the appropriate administrative, physical and technical safeguards should be in place that ensure the confidentiality, integrity, and security of electronic protected health information. The physical environments at both the originating and distant site are clinical environments and the spaces should reflect that.
The location of the room for the encounter at both ends should ensure comfort, privacy, and confidentiality. Both visual and audio privacy are important, placement and selection of the rooms should consider this. An appropriate certified or licensed health care professional at the originating site is required to present the member to the physician or practitioner at the distant site and remain available as clinically appropriate.
(6) The health care practitioner must obtain written consent from the SoonerCare member that states they agree to participate in the telemedicine-based office visit. The consent form must include a description of the risks, benefits and consequences of telemedicine and be included in the member's medical record.
(7) If the member is a minor child, a parent/guardian must present the minor child for telemedicine services unless otherwise exempted by State or Federal law. The parent/guardian need not attend the telemedicine session unless attendance is therapeutically appropriate.
(8) The member retains the right to withdraw at any time.
(9) All telemedicine activities must comply with the HIPAA Security Standards, OHCA policy, and all other applicable state and federal laws and regulations.
(10) The member has access to all transmitted medical information, with the exception of live interactive video as there is often no stored data in such encounters.
(11) There will be no dissemination of any member images or information to other entities without written consent from the member.
(1) A facility fee will be paid to the originating site when the appropriate telemedicine facility fee code is used.
(A) Hospital outpatient: When the originating site is a hospital outpatient department, payment for the originating site facility fee will be paid according to the SoonerCare fee schedule.
(B) Hospital inpatient: For hospital inpatients, payment for the originating site facility fee will be paid outside the Diagnostic Related Group (DRG) payment.
(C) FQHCs and RHCs: The originating site facility fee for telemedicine services is not an FQHC or RHC service. When an FQHC or RHC serves as the originating site, the originating site facility fee is paid separately from the center or clinic all-inclusive rate.
(D) Facilities of the Indian Health Service, tribal facilities or Urban Indian Clinics: When an I/T/U serves as the originating site, the originating site facility fee is reimbursed outside the OMB rate.
(E) Physicians'/practitioners' offices: When the originating site is a physician's office, the originating site facility fee will be paid according to the SoonerCare fee schedule. If a provider from the originating site performs a separately identifiable service for the member on the same day as telemedicine, documentation for both services must be clearly and separately identified in the member's medical record.
(2) Services provided by telemedicine must be billed with the appropriate modifier. Only the portion of the telemedicine service rendered from the distant site is billed with the modifier. Coding and billing the appropriate modifier with a covered telemedicine procedure code, the distant site provider and/or practitioner certifies that the member was present at the originating site when the telemedicine service was furnished.
(3) If the technical component of an X-ray, ultrasound or electrocardiogram is performed at the originating site during a telemedicine transmission, the technical component and a telemedicine facility fee are billed by the originating site. The professional component of the procedure and the appropriate visit code are billed by the distant site.
(4) Reimbursement for telemedicine services is available only when the originating site is located in a geographic area where there is a lack of medical/psychiatric/behavioral health expertise and the distance from the originating and distant site is greater than 20 miles apart, with few exceptions. The OHCA may make an exception to this requirement based on geographic limitations and service constraints. The OHCA has discretion and the final authority to approve or deny any telemedicine services based on agency and/or SoonerCare members' needs. Services are not reimbursable when provided primarily for the convenience of the provider. Adequate documentation must be maintained as service is subject to post payment review. Post payment review may result in adjustments to payment when a telemedicine modifier isbilled inappropriately or not billed when appropriate.
(5) The cost of telemedicine equipment and transmission is not reimbursable by SoonerCare.
(1) Documentation must be maintained at the originating and the distant locations to substantiate the services provided.
(2) Documentation must indicate the services were rendered via telemedicine, the location of the originating and distant sites, and which OHCA approved network was used.
(3) All other SoonerCare documentation guidelines apply to the services rendered via telemedicine. Examples include but are not limited to:
(A) Chart notes;
(B) Start and stop times;
(C) Service provider's credentials; and
(D) Provider's signature.
(i) Telemedicine network standards. In order to be an approved telemedicine network, an applicant must be contracted with the OHCA and meet certain technical and privacy standards stated within the contract in order to ensure the highest quality of care. Contracted networks must complete HIPAA Security Risk and Mobile Device Analysis associated with remote access to, and offsite use of, Electronic Protected Health Information (ePHI). Networks must develop and implement risk management measures to assure the safeguard of ePHI. The OHCA has discretion and the final authority to approve or deny any telemedicine network based on agency and/or SoonerCare members' needs.
(j) Telemedicine provider responsibilities. Providers must adhere to privacy standards for the confidentiality, integrity, and security of ePHI. Privacy standards include but are not limited to the following:
(1) Complying with Health Insurance Portability and Accountability Act (HIPAA) and security protection for the member in connection with the telemedicine communication and related records.
(2) Submitting a Mobile Device Security Assessment to the OHCA Provider Enrollment Unit, to assure that SoonerCare members' ePHI will not be compromised. Providers are required to attest to compliance with applicable provisions of HIPAA and submit one of the following:
(A) A completed OHCA Provider HIPAA Mobile Device Security Assessment form; or
(B) A copy of the provider's most recent HIPAA Security Assessment, mobile device section only, with any risk compromising wording redacted.
(3) Obtaining and maintaining technology used in the telemedicine communication that is compliant with privacy and security standards in HIPAA, and OHCA Provider and Network Contracts.
(4) Ensuring policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records to unauthorized persons.
(5) Maintaining clinical documentation.
|317:30-3-28.||Electronic Health Records Incentive Program|
(a) Program. The Oklahoma Electronic Health Records Incentive Program is authorized by the American Recovery and Reinvestment Act of 2009. Under this program, SoonerCare providers may qualify for incentive payments if they meet the eligibility guidelines in this section and demonstrate they are engaged in efforts to adopt, implement, upgrade, or meaningfully use certified electronic health records (EHR) technology. The EHR incentive program is governed by the policy in this section and the Electronic Health Records Program Final Rule issued by CMS in CMS-0033-F and 45 CFR 170. Providers should also use the EHR program manual as a reference for additional program details.
(b) Eligible providers. To qualify for incentive payments, a provider must be an "eligible professional" or an "eligible hospital." Providers who receive incentive payments must have an existing Provider Agreement with OHCA.
(1) Eligible professionals. An eligible professional is defined as a physician, a physician assistant practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) led by a physician assistant, a board certified pediatrician, a nurse practitioner, a certified nurse midwife, or a dentist. OHCA will determine eligibility based on the provider type, specialty associated with the provider in the MMIS system, and documentation.
(A) Eligible professionals may not be hospital-based, unless they practice predominantly at an FQHC or RHC as defined by the CMS Final Rule. A "hospital-based" professional furnishes ninety percent (90%) or more of their SoonerCare-covered professional services during the relevant EHR reporting period in a hospital setting, whether inpatient or Emergency Room, through the use of the facilities and equipment of the hospital. Specific exclusions to the "hospital-based" definition may be allowed by federal law and are detailed in the EHR Incentive Program provider manual.
(B) Eligible professionals may not participate in both the Medicaid and Medicare EHR incentive payment program during the same payment year.
(2) Eligible hospitals. Eligible hospitals are Children's Hospitals or Acute Care Hospitals, including Critical Access Hospitals and cancer hospitals. An Acute Care Hospital is defined as a health care facility where the average length of patient stay is twenty-five (25) days or fewer and that has a CMS certification number that has the last four digits in the series 0001-0879 and 1300-1399. A Children's Hospital is defined as a separately certified children's hospital, either freestanding or hospital-within-hospital, that predominantly treats individuals under 21 years of age and has a CMS certification number with the last 4 digits in the series 3300-3399 or, if it does not have a CMS certification number, has been provided an alternative number by CMS for purposes of enrollment in the Medicaid EHR incentive program. Hospitals that do not meet either of the preceding definitions are not eligible for incentive payments.
(c) Patient volume. Eligible professionals and eligible hospitals must meet SoonerCare patient volume criteria to qualify for incentive payments. Patient volume criteria compliance will be verified by the OHCA through claims data and provider audits. When calculating SoonerCare patient volume, all SoonerCare populations may be counted. To calculate patient volume, the provider's total SoonerCare patient encounters in the specified reporting period must be divided by the provider's total patient encounters in the same reporting period.
(1) Eligible professionals. Eligible professionals must meet a 30% SoonerCare patient volume threshold over a continuous 90-day period in the preceding calendar year or the preceding 12 month period from the date of attestation. The only exception is for pediatricians, as discussed in OAC 317:30-3-28(c)(5).
(2) Eligible hospitals. With the exception of children's hospitals, which have no patient volume requirement, eligible hospitals must meet a 10% SoonerCare patient volume threshold over a continuous 90-day period in the preceding calendar year or over the most recent continuous 12 month period for which data are available prior to the payment year.
(3) FQHC or RHC patient volume. Eligible professionals practicing predominantly in an FQHC or RHC may be evaluated according to their "needy individual" patient volume. To qualify as a "needy individual," patients must meet one of the following criteria:
(A) Received medical assistance from SoonerCare;
(B) Were furnished uncompensated care by the provider; or
(C) Were furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay.
(4) Clinics and group practices. Clinics or group practices may calculate patient volume using the clinic's or group's SoonerCare patient volume under the following conditions:
(A) The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the eligible professional;
(B) There is an auditable data source to support the patient volume determination;
(C) All eligible professionals in the clinic or group practice use the same methodology for the payment year;
(D) The clinic or group practice uses the entire practice's patient volume and does not limit patient volume in any way; and
(E) If an eligible professional works inside and outside of the clinic or practice, the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the eligible professional's outside encounters.
(5) Pediatricians. Pediatricians may qualify for 2/3 incentive payments if their SoonerCare patient volume is 20-29%. A pediatrician is defined as a medical doctor who diagnoses, treats, examines, and prevents diseases and injuries in children and possesses a valid, unrestricted medical license and board certification in Pediatrics through either the American Board of Pediatrics (ABP) or the American Osteopathic Board of Pediatrics (AOBP). To qualify as a pediatrician for the purpose of receiving a 2/3 payment under the incentive program, the provider must provide OHCA with a copy of their pediatric licenses and board certification.
(6) Out of state patients. For eligible professionals and eligible hospitals using out of state Medicaid recipients for patient volume requirement purposes, the provider must retain proof of the encounter for the out of state patient.
(d) Attestation. Eligible professionals and eligible hospitals must execute an amendment to their SoonerCare Provider Agreement to attest to meeting program criteria through the Electronic Provider Enrollment (EPE) system in order to qualify for incentive payments. Registration in the CMS EHR Incentive Payment Registration and Attestation system is a pre-requisite to EPE attestation.
(e) Adoption/ Implementation/ Upgrade (A/I/U). Eligible professionals or eligible hospitals in their first participation year under the Oklahoma EHR Incentive Payment Program may choose to attest to adopting, implementing, or upgrading certified EHR technology. Proof of A/I/U must be submitted to OHCA in order to receive payment.
(f) Meaningful use. Eligible professionals in their second through sixth participation year and eligible hospitals in their second through third participation year must attest to meaningful use of certified EHR technology. Eligible hospitals must attest to meaningful use if they are participating in both the Medicare and Oklahoma EHR Incentive Programs in their first participation year. The definition of "meaningful use" is outlined in, and determined by, the Electronic Health Records Program Final Rule CMS-0033-F.
(g) Payment. Eligible professionals may receive a maximum of $63,750 in incentive payments over six years. Providers must begin their participation by 2016 to be eligible for payments. Payments will be made one time per year per provider and will be available through 2021. Eligible hospitals cannot initiate payments after 2016 and payment years must be consecutive after 2016.
(1)Eligible professionals and eligible hospitals must use a Taxpayer Identification Number (TIN) to assign a valid entity as the incentive payments recipient. Valid entities may be the individual provider or a group with which the provider is associated. The assigned payee must have a current Provider Agreement with OHCA.
(2) The provider is responsible for repayment of any identified overpayment. In the event OHCA determines monies have been paid inappropriately, OHCA will recoup the funds by reducing any future payments owed to the provider.
(h) Administrative appeals. Administrative appeals of decisions related to the Oklahoma Electronic Health Records Incentive Program will be handled under the procedures described in OAC 317:2-1-2(b). The only exception to this section is when CMS conducts meaningful use audits. Results of any adverse CMS audits are subject to the CMS administrative appeals process and not the state appeal process.
|317:30-3-29.||Revisions of provider fee schedules|
(a) The Oklahoma Health Care Authority (OHCA) reserves the right to review and/or update and adjust provider fee schedules. Provider fee schedules will be reviewed annually and adjustments to the fee schedules may be made at any time based on efficiency, budget considerations, economy, and quality of care. The OHCA assures that all payments will be sufficient to enlist enough providers so that care and services are available under the State Plan at least to the extent that such care and services are available to the general population in the geographic area. The OHCA may issue revisions to provider fee schedules during the year that they are effective. Providers will be notified of any revisions to the fee schedule and the revision effective dates. Provider fee schedules, when reviewed and changed, are posted to the OHCA's website in relation to the current State Fiscal Year. The OHCA will adjust provider fee schedules to:
(1) comply with changes in state or federal requirements;
(2) comply with changes in nationally recognized coding systems, such as Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT);
(3) establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and
(4) adjust the allowable amount when the OHCA determines that the current allowable amount is:
(A) not appropriate for the service provided; or
(B) based on errors in data or calculation.
(b) The OHCA will provide public notice, unless specified below, of any significant proposed change in its methods and standards for setting provider payment rates for services. The OHCA will not provide notice if:
(1) the change is being made to conform to Medicare methods or levels of reimbursement;
(2) the change is required by a court order; or
(3) the change is based on changes in wholesalers' or manufacturers' prices of drugs or materials.
(a) For medical review purposes, the Oklahoma Health Care Authority (OHCA) requires that all services provided and/or ordered be authenticated by the author. The method used shall be a hand written signature, electronic signature, or signature attestation statement. Stamped signatures are not acceptable. Pursuant to federal and/or state law, there are some circumstances for which an order does not need to be signed.
(1) Facsimile of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
(2) Orders for clinical diagnostic tests are not required to be signed. If the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a hand written or electronic signature.
(3) Orders for outpatient prescription drugs are not required to be signed. If the order for a prescription drug is unsigned, there must be medical documentation by the treating physician that he/she intended that the prescription drug be ordered. This documentation showing the intent that the prescription drug be ordered must be authenticated by the author via a hand written or electronic signature.
(b) A hand written signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.
(1) If a signature is illegible, the OHCA will consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
(2) If the signature is missing from an order, the OHCA will disregard the order during the review of the claim.
(3) If the signature is missing from any other medical documentation, the OHCA will accept a signature attestation from the author of the medical record entry.
(c) Providers may include in the documentation they submit a signature log that lists the typed or printed name of the author associated with initials or an illegible signature.
(1) The signature log may be included on the actual page where the initials or illegible signature are used or may be a separate document.
(2) The OHCA will not deny a claim for a signature log that is missing credentials.
(3) The OHCA will consider all submitted signature logs regardless of the date they were created.
(d) Providers may include in the documentation they submit a signature attestation statement. In order to be considered valid for medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the member.
(1) The OHCA will not consider signature attestation statements where there is no associated medical record entry.
(2) The OHCA will not consider signature attestation statements from someone other than the author of the medical record entry in question.
(3) The OHCA will consider all signature attestation statements that meet the above requirements regardless of the date the attestation was created, except in those cases where the regulations or rules indicate that a signature must be in place prior to a given event or a given date.
(e) Providers may use electronic signatures as an alternate signature method.
(1) Providers must use a system and software products which are protected against modification and must apply administrative procedures which are adequate and correspond to recognized standards and laws.
(2) Providers utilizing electronic signatures bear the responsibility for the authenticity of the information being attested to.
(3) Providers utilizing electronic signatures must comply with OAC 317:30-3-4.1.
(f) Nothing in this section is intended to absolve the provider of their obligations in accordance with the conditions set forth in their SoonerCare contract and the rules delineated in OAC 317:30.