(a) All general medical/surgical hospitals and critical access hospitals eligible for reimbursement under this Part must be licensed by the appropriate state survey agency, meet Medicare conditions of participation, and have a current contract on file with the Oklahoma Health Care Authority (OHCA).
(b) Children specialty hospitals must be appropriately licensed and certified and have a current contract with the OHCA.
(c) Eligibility requirements for specialized rehabilitation hospitals are covered in OAC 317:30-5-110; inpatient psychiatric hospitals are covered in OAC 317:30-5-95. Requirements for long term care hospitals are found in OAC 317:30-5-60.
(d) Certain providers who provide professional and other services within an inpatient or outpatient hospital require separate contracts with the OHCA.
(e) Reimbursement for laboratory services is made in accordance with the Clinical Laboratory Improvement Amendment of 1988 (CLIA). These regulations provide that payment may be made only for services furnished by a laboratory that meets CLIA conditions. Eligible providers must be certified under the CLIA program and have obtained a CLIA ID number from the Center for Medicare and Medicaid Services (CMS) and have a current contract on file with this Authority.
(a) This Chapter applies to coverage in an inpatient and/or outpatient setting. Coverage is the same for adults and children unless otherwise indicated.
(b) Professional Services. Payment is made to a participating hospital group or corporation for hospital based physician's services. The hospital must have a Hospital Group Physician's Contract with OHCA for this method of billing.
(c) Prior Authorization. OHCA requires prior authorization for certain procedures to validate the medical need for the service.
(d) Medical necessity. Medical necessity requirements are listed at OAC 317:30-3-1(f).
The following words and terms, when used in this Part, shall have the following meaning, unless the context clearly indicates otherwise.
"CMS" means the Center for Medicare and Medicaid Services
"Diagnosis Related Group" means a patient classification system that relates types of patients treated to the resources they consume.
|317:30-5-41.||Inpatient hospital coverage/limitations|
(a) Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients and which are provided under the direction of a physician or dentist in an institution approved under OAC:317:30:5-40.1(a) or (b) Claims for inpatient admissions in acute care or critical access hospitals are reimbursed the lesser of the billed charges or the Diagnosis Related Groups (DRG) amount.
(b) Inpatient status. OHCAconsiders a member an inpatient when the member is admitted to the hospital and is counted in the midnight census. In situations when a member inpatient admission occurs and the member dies, is discharged following an obstetrical stay, or is transferred to another facility on the day of admission, the member is also considered an inpatient of the hospital.
(1) Same day admission. If a member is admitted and dies before the midnight census on the same day of admission, the member is considered an inpatient.
(2) Same day admission/discharge - obstetrical and newborn stays. A hospital stay is considered inpatient stay when a member is admitted and delivers a baby, even when the mother and baby are discharged on the date of admission (i.e., they are not included in the midnight census). This rule applies when the mother and/or newborn are transferred to another hospital.
(3) Same day admission/discharges other than obstetrical and newborn stays. In the event a member is admitted as an inpatient, but is determined to not qualify for an inpatient payment based on OHCA criteria, the hospital may bill on an outpatient claim for the ancillary services provided during that time.
(4) Discharges and Transfers. A hospital inpatient is considered discharged from a hospital paid under the DRG-based payment system when:
(A) The patient is formally released from the hospital; or
(B) The patient dies in the hospital; or
(C) The patient is transferred to a hospital that is excluded from the DRG-based payment system, or transferred to a distinct part psychiatric or rehabilitation unit of the same hospital. Such instances will result in two or more claims. Effective January 1, 2007, distinct part psychiatric and rehabilitation units excluded from the Medicare Prospective Payment System (PPS) of general medical surgical hospitals will require a separate provider identification number.
|317:30-5-41.1.||Acute inpatient psychiatric services|
(a) Inpatient stays in a psychiatric unit of a general medical/ surgical hospital are covered for members of any age. See OAC 317:30-5-95 for coverage in a freestanding psychiatric hospital or psychiatric residential treatment facility.
(b) Utilization Control. All psychiatric admissions must be prior authorized. SoonerCare utilization control requirements applicable to inpatient psychiatric services in freestanding psychiatric hospitals apply to acute care hospitals. Acute care hospitals are required to maintain the same level of documentation on individuals receiving psychiatric services as the freestanding psychiatric facilities (refer to OAC 317:30-5-95.12).
Solid organ and bone marrow/stem cell transplants are covered when appropriate and medically necessary.
(1) Transplant procedures, except kidney and cornea, must be prior authorized to be compensable.
(2) To be prior authorized all procedures are reviewed based on appropriate medical criteria.
(3) To be compensable under the SoonerCare program all transplants must be performed at a facility which meets the requirements contained in Section 1138 of the Social Security Act.
(4) Procedures considered experimental or investigational are not covered.
(5) Donor search and procurement services are covered for transplants consistent with the methods used by the Medicare program for organ acquisition costs.
|317:30-5-42.||Coverage for children [REVOKED]|
|317:30-5-42.1.||Outpatient hospital services|
(a) Hospitals providing outpatient hospital services are required to meet the same requirements that apply to OHCA contracted, non-hospital providers performing the same services. Outpatient services performed outside the hospital facility are not reimbursed as hospital outpatient services.
(b) Covered outpatient hospital services must meet all of the criteria listed in (1) through (4) of this subsection.
(1) The care is directed by a physician or dentist.
(2) The care is medically necessary.
(3) The member is not an inpatient (see OAC 317:30-5-41).
(4) The service is provided in an approved hospital facility.
(c) Covered outpatient hospital services are those services provided for a member who is not a hospital inpatient. A member in a hospital may be either an inpatient or an outpatient, but not both (see OAC 317:30-5-41).
(d) In the event a member is admitted as an inpatient, but is determined to not qualify for an inpatient payment based on OHCA criteria, the hospital may bill on an outpatient claim for the ancillary services provided during that time.
(e) Separate payment is made for prosthetic devices inserted during the course of surgery when the prosthetic devices are not integral to the procedure and are not included in the reimbursement for the procedure itself.
(f) Physical, occupational, and speech therapy services are covered when performed in an outpatient hospital based setting. Coverage is limited to one evaluation/re-evaluation visit (unit) per discipline per calendar year and 15 visits (units) per discipline per date of service per calendar year. Claims for these services must include the appropriate revenue code(s).
|317:30-5-42.2.||Blood and blood fractions|
Payment is made for blood and blood fractions and the administration of blood and blood fractions when these products are required for the treatment of a congenital or acquired disease of the blood and not available from another source.
|317:30-5-42.3.||Chemotherapy and radiation therapy|
Payment is made for charges incurred for the administration of chemotherapy for the treatment of medically necessary and medically approved procedures. Payment for radiation therapy is limited to the treatment of proven malignancies and benign conditions appropriate for sterotactic radiosurgery (e.g., gamma knife).
|317:30-5-42.4.||Clinic/treatment room services; urgent care|
(a) An outpatient hospital clinic is a non-emergency service providing diagnostic, preventive, curative and rehabilitative services on a scheduled basis.
(b) Urgent care payment is made for services provided in non-emergency clinics operated by a hospital. This payment does not include the professional charges of the treating physician, nurse practitioner, physician assistant or charges for diagnostic testing. A facility charge is also allowed when drug and/or blood are administered outpatient.
(c) Urgent Care services will not require a referral for SoonerCare Choice members however other claims will deny without a referral.
(d) Adults are limited to four clinic visits per month.
|317:30-5-42.5.||Diagnostic testing therapeutic services|
(a) Reimbursement is made for diagnostic testing to diagnose a disease or medical condition.
(b) Separate payment may be made for ancillary services that are not covered as an integral part of a facility fee.
Payment for dialysis is made at the Medicare prospective payment system wage adjusted base rate. This rate includes all services which Medicare has established as an integral part of the dialysis procedure. The physician is reimbursed separately.
|317:30-5-42.7.||Emergency department (ED) care/services|
Emergency department care must:
(1) Be provided in a hospital with a designated emergency department; and
(2) Provide direct patient care, including patient assessment, monitoring, and treatment by hospital medical personnel such as physicians, nurses, or lab and x-ray technicians.
(A) Medical records must document the emergency diagnosis and the extent of direct patient care.
(B) Emergency department care does not include unattended waiting time.
(C) Emergency services are covered for a medical emergency. This means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
(i) Placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or continuation of severe pain;
(ii) serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or death.
(D) Labor and delivery is a medical emergency, if it meets this definition.
(3) Prescheduled services are not considered an emergency.
(4) Services provided as follow-up to initial emergency care are not considered emergency services.
|317:30-5-42.8.||Hearing and speech therapy|
Payment is covered for hearing and speech services, including evaluations, for children when prior authorized.
Intramuscular, subcutaneous or intravenous injections and intravenous (IV) infusions are covered when medically necessary and not considered a compensable part of the procedure.
Payment is made for all laboratory tests listed in the Clinical Diagnostic Laboratory fee schedule from CMS. To be eligible for payment as a laboratory/pathology service, the service must be:
(1) Ordered and provided by or under the direction of a physician or other licensed practitioner within the scope of practice as defined by state law;
(2) Provided in a hospital or independent laboratory;
(3) Directly related to the diagnosis and treatment of a medical condition; and
(4) Authorized under the laboratory's CLIA certification.
(a) Payment is made for the use of a treatment room associated with outpatient observation services. Observation services must be ordered by a physician or other individual authorized by state law. Observation services are furnished by the hospital on the hospital's premises and include use of the bed and periodic monitoring by hospital staff. Observation services must include a minimum of 8 hours of continuous care. Outpatient observation services are not covered when they are provided:
(1) On the same day as an emergency department visit.
(2) Prior to an inpatient admission, as those observation services are considered part of the inpatient DRG.
(3) For the convenience of the member, member's family or provider.
(4) When specific diagnoses are not present on the claim.
(5) As part of another service, i.e. for post operative monitoring; recovery after diagnostic testing or concurrently with therapeutic services such as chemotherapy.
(b)Payment is made for observation services in a labor or delivery room. Specific pregnancy-related diagnoses are required. During active labor, a fetal non-stress test is covered in addition to the labor and delivery room charge.
Payment is made for preauthorized outpatient physical therapy, including evaluations, for children.
Payment is made for the technical component of outpatient radiation therapy and compensable x-ray procedures.
(1) Mammograms. Medically necessary screening mammography is a covered benefit. Additional follow-up mammograms are covered when medically necessary.
(2) Ultrasounds. Ultrasounds for obstetrical care are paid in accordance with provisions found at OAC 317:30-5-22(b)(2)(A)-(C).
|317:30-5-42.14.||Surgery and diagnostic services|
(a) Ambulatory Patient Classification (APC) Groups. All outpatient hospital services paid under the Medicare Outpatient Prospective Payment System (OPPS) are classified into groups called Ambulatory Payment Classifications or APCs. Group services identified by Health Care Procedure Coding System (HCPCS) codes and descriptors within APC groups are the basis for setting payment rates under OPPS. Services in each APC are similar clinically and in terms of the resources they require. The payment rate calculated for an APC applies to all of the services assigned to the APC. Depending on the services provided, a hospital may receive a number of APC payments for the services furnished to a member on a single day.
(b) Reimbursement. Reimbursement is made for selected services performed in an outpatient hospital. Hospital outpatient services are paid on a rate-per-service basis that varies according to the Ambulatory Payment Classification (APC) group to which the services are assigned.
(c) Multiple Surgeries. Multiple procedures furnished during the same visit are discounted. The full amount is paid for the procedure with the highest payment group. Fifty percent is paid for any other surgical procedure(s) performed at the same time if the procedure is subject to discounting based on the status indicator established by Medicare.(d) Status indicators. Status indicators identify whether the service described by a HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged and if payment is subject to discounting. SoonerCare follows Medicare's guidelines for packaged/bundled service costs.
(e) Minor procedures. Minor procedures that are normally performed in a physician's office are not covered in the outpatient hospital unless medically necessary.
(f) Ambulatory Surgery. When an ambulatory surgery is performed in the inpatient hospital setting, the physician must provide exception rationale justifying the need for an inpatient setting to OHCA medical staff for review.
(g) Dental Procedures. Routine dental procedures that are normally performed in a dentist's office are not covered in an outpatient hospital setting unless medically necessary as determined by OHCA. For OHCA payment purposes, the APC list has been expanded to cover dental services for adults in an ICF/MR and all children.
(1) Non-emergency routine dental that is provided in an outpatient hospital setting is covered under the following circumstances:
(A) The child has a medical history of uncontrolled bleeding or other medical condition which renders in-office treatment impossible.
(B) The child has uncontrollable behavior in the dental office even with premedication.
(C) The child needs extensive dental procedures or oral surgery procedures.
(2) Non-emergency routine dental that is provided in an outpatient hospital setting is covered for children and/or adults who are residents in ICFs/MR only under the following circumstances:
(A) A concurrent hazardous medical condition exists;
(B) The nature of the procedure requires hospitalization or;
(C) Other factors (e.g. behavioral problems due to mental impairment) necessitate hospitalization.
|317:30-5-42.15.||Outpatient hospital services for members infected with tuberculosis|
Outpatient hospital services are covered for members infected with tuberculosis. Coverage includes, but may not be limited to, outpatient hospital visits, laboratory work and x-rays.
(1) Services to members infected with TB are not limited to the scope of the SoonerCare program; however, prior authorization is required for services that exceed the scope of coverage under SoonerCare.
(2) Drugs prescribed for the treatment of TB not in accordance with OAC 317:30-3-46 require prior authorization by the OHCA Pharmacy Helpdesk using form "Petition for TB Related Therapy."
(a) Ambulance. Ambulance services furnished by the facility are covered separately if otherwise compensable under the Authority's Medical Programs.
(b) Home health care. Hospital based home health providers must be Medicare certified and have a current Home Health Agency contract with the OHCA.
(1) Payment is made for home health services provided in a member's residence to all categorically needy individuals.
(2) Payment is made for a maximum of 36 visits per year for eligible members 21 years of age or older. Payment for any combination of skilled and home health aide visits can not exceed 36 visits per year.
(3) Payment is made for standard medical supplies.
(4) Payment is made on a rental or purchase basis for equipment and appliances suitable for use in the home.
(5) Non-covered items include sales tax, enteral therapy and nutritional supplies, and electro-spinal orthosis systems (ESO).
(6) Payment may be made to home health agencies for prosthetic devices.
(A) Coverage of oxygen includes rental of liquid oxygen systems, gaseous oxygen systems and oxygen concentrators when prior authorized. Purchase of oxygen systems may be made where unusual circumstances exist and purchase is considered most appropriate.
(B) Payment is made for permanent indwelling catheters, drain bags, insert trays and irrigation trays. Male external catheters are also covered.
(C) Sterile tracheotomy trays are covered.
(D)Payment is made for colostomy and urostomy bags and accessories.
(E) Payment is made for hyperalimentation, including supplements, supplies and equipment rental on behalf of persons having permanently inoperative internal body organ dysfunction. Information regarding the member's medical condition that necessitates the hyperalimentation and the expected length of treatment, should be attached when requesting prior authorization.
(F) Payment is made for ventilator equipment and supplies when prior authorized.
(G)Payment for medical supplies, oxygen, and equipment is made when using appropriate HCPCS codes which are included in the HCPCS Level II Coding Manual.
(c) Hospice Services. Hospice is defined as palliative and/or comfort care provided to the member family when a physician certifies that the member has a terminal illness and has a life expectancy of six months or less. A hospice program offers palliative and supportive care to meet the special needs arising out of the physical, emotional and spiritual stresses which are experienced during the final stages of illness and death. Hospice services must be related to the palliation and management of the member's illness, symptom control, or to enable the individual to maintain activities of daily living and basic functional skills.
(1) Payment is made for home based hospice services for terminally ill individuals under the age of 21 with a life expectancy of six months or less when the member and/or family has elected hospice benefits. Hospice services are available to eligible members without forgoing any other service to which the member is entitled under SoonerCare for curative treatment of the terminal illness. Once the member has elected hospice care, the hospice medical team assumes responsibility for the member's medical care for the terminal illness in the home environment. Hospice providers are not responsible for curative treatments for members that elect such services while on hospice. Hospice care includes nursing care, physician services, medical equipment and supplies, drugs for symptom control and pain relief, home health aide and personal care, physical, occupational and/or speech therapy, medical social services, dietary counseling and grief and bereavement counseling to the member and/or family.
(2) Hospice care is available for two initial 90-day periods and an unlimited number of subsequent 60-day periods during the remainder of the member's lifetime. Beginning January 1, 2011, a hospice physician or nurse practitioner must have a face to face encounter with the member to determine if the member's terminal illness necessitates continuing hospice care services. The encounter must take place prior to the 180th day recertification and each subsequent recertification thereafter; and attests that such visit took place. The member and/or the family may voluntarily terminate hospice services.
(3) Hospice services must be reasonable and necessary for the palliation or management of a terminal illness or related conditions. A certification that the member is terminally ill must be completed by the member's attending physician or the Medical Director of an Interdisciplinary Group. Nurse practitioners serving as the attending physician may not certify the terminal illness; however, effective January 1, 2011, nurse practitioners may re-certify the terminal illness.
(4) Services must be prior authorized. A written plan of care must be established before services are provided. The plan of care should be submitted with the prior authorization request.
In addition to the general program exclusions [OAC317:30-5-2(a)(2)] the following are excluded from coverage:
(1) Inpatient admission for diagnostic studies that could be performed on an outpatient basis.
(2) Procedures that result in sterilization which do not meet the guidelines set forth in this Chapter of rules.
(3) Reversal of sterilization procedures for the purposes of conception are not covered.
(4) Medical services considered experimental or investigational.
(5) Payment for removal of benign skin lesions for adults.
(7) Charges incurred while the member is in a skilled nursing or swing bed.
(8) Sleep studies for adults.
|317:30-5-42.18.||Coverage for children|
(a) Services, deemed medically necessary and allowable under federal Medicaid regulations, may be covered under the EPSDT/OHCA Child Health program even though those services may not be part of the Oklahoma Health Care Authority SoonerCare program. Such services must be prior authorized.
(b) Federal Medicaid regulations also require the State to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or which are considered experimental.
|317:30-5-42.19.||340B Drug Discount Program|
Drug Discount Program guidelines refer to section 317:30-5-87.
|317:30-5-43.||Vocational Rehabilitation coverage [REVOKED]|
|317:30-5-44.||Medicare eligible individuals|
Payment is made to hospitals for services to Medicare eligible individuals as set forth in this section.
(1) Claims filed with Medicare automatically cross over to OHCA. The explanation of Medicare Benefits (EOMB) reflects a message that the claim was referred to SoonerCare. If such a message is not present, a claim for coinsurance and deductible must be filed with the OHCA within 90 days of the date of Medicare payment and within one year of the date of service in order to be considered timely filed.
(2) If payment is denied by Medicare and the service is a SoonerCare covered service, mark the claim "denied by Medicare" and attach the Medicare EOMB showing the reason for denial.
(3) In certain circumstances, some claims do not automatically "cross over". Providers must file a claim for coinsurance and/or deductible to SoonerCare within 90 days of the Medicare payment and within one year from the date of service.
(4) For individuals who have exhausted Medicare Part A benefits, claims must be accompanied by a statement from the Medicare Part A intermediary showing the date benefits were exhausted.
|317:30-5-45.||Psychiatric hospitals - inpatient services for persons age 65 and over [REVOKED]|
|317:30-5-46.||Psychiatric hospitals and residential psychiatric treatment facilities - inpatient services for persons under age 21 [REVOKED]|
|317:30-5-47.||Reimbursement for inpatient hospital services|
Reimbursement will be made for inpatient hospital services in the following manner:
(1) Covered inpatient services provided to eligible SoonerCare members admitted to in-state acute care and critical access hospitals will be reimbursed the lesser of the billed charges or the Diagnosis Related Group (DRG) amount. In addition to the billed charges or DRG payment, whichever is less, an outlier payment may be made to the hospital for very high cost stays. Additional outlier payment is applicable if either the amount billed by the hospital or DRG payment, whichever applies, is less than a threshold amount of the hospital cost. Each inpatient hospital claim is tested to determine whether the claim qualified for a cost outlier payment. Payment is equal to a percentage of the cost after the threshold is met.
(2) The lesser of the billed charges or DRG amount and outlier, if applicable, represent full reimbursement for all non-physician services provided during the inpatient stay. Payment includes but is not limited to:
(A) laboratory services;
(B) prosthetic devices, including pacemakers, lenses, artificial joints, cochlear implants, implantable pumps;
(C) technical component on radiology services;
(D) transportation, including ambulance, to and from another facility to receive specialized diagnostic and therapeutic services;
(E) pre-admission diagnostic testing performed within 72 hours of admission; and
(F) organ transplants.
(3) Hospitals may submit a claim for payment only upon the final discharge of the patient or upon completion of a transfer of the patient to another hospital.
(4) Covered inpatient services provided to eligible members of the Oklahoma SoonerCare program, when treated in out-of-state hospitals will be reimbursed in the same manner as in-state hospitals.
(5) Cases which indicate transfer from one acute care hospital to another will be monitored under a retrospective utilization review policy to help ensure that payment is not made for inappropriate transfers.
(6) The transferring hospital will be paid the lesser of the calculated transfer fee or the DRG base payment amount for a non-transfer.
(7) If the transferring or discharge hospital or unit is exempt from the DRG, that hospital or unit will be reimbursed according to the method of payment applicable to the particular facility or units.
(8) Covered inpatient services provided in out-of-state specialty hospitals may be reimbursed at a negotiated rate not to exceed 100% of the cost to provide the service. Negotiation of rates will only be allowed when the OHCA determines that the specialty hospital or specialty unit provides a unique (non-experimental) service required by SoonerCare members and the provider will not accept the DRG payment rate. Prior authorization is required.
(9) New providers entering the SoonerCare program will be assigned a peer group and will be reimbursed at the peer group base rate for the DRG payment methodology or the statewide median rate for per diem methods.
(10) When services are delivered via telemedicine to hospital inpatients, the originating site facility fee will be paid outside the DRG payment.
(11) All inpatient services are reimbursed per the methodology described in this section and/or as approved under the Oklahoma State Medicaid Plan.
|317:30-5-47.1.||Reimbursement for newborn screening services provided by the OSDH|
Newborn screening performed by the Oklahoma State Department of Health in accordance with State Law is excluded from the inpatient DRG payment.
|317:30-5-47.2.||Disproportionate share hospitals (DSH)|
Payment will be made to hospitals qualifying for Disproportionate Share Hospital adjustments pursuant to the methodology described in the Oklahoma Title XIX Inpatient Hospital State Plan.
|317:30-5-47.3.||Indirect medical education (IME) adjustment|
Payment will be made to hospitals qualifying for Indirect Medical Education payment adjustments pursuant to the methodology described in the Oklahoma Title XIX Inpatient Hospital State Plan.
|317:30-5-47.4.||Direct medical education payment adjustment|
Payment will be made to hospitals qualifying for Direct Medical Education payment adjustments pursuant to the methodology described in the Oklahoma Title XIX Inpatient Hospital State Plan.
|317:30-5-47.5.||Critical Access Hospitals|
Critical Access Hospitals (CAHs) are rural public or non-profit hospitals which have been certified by Medicare as a Critical Access Hospital. The facility must provide documentation to be determined eligible for the CAH peer group.
|317:30-5-48.||Cost reports [REVOKED]|
(a) Instances of child abuse and/or neglect are to be reported in accordance with State Law. Section 7103 of Title 10 of the Oklahoma Statutes mandates reporting suspected abuse or neglect to the Oklahoma Department of Human Services. Section 7104 of Title 10 of the Oklahoma Statutes further requires reporting of criminally injurious conduct to the nearest law enforcement agency.
(b) Each hospital must designate a person, or persons, within the facility who is responsible for reporting suspected instances of medical neglect, including instances of withholding of medically indicated treatment (including appropriate nutrition, hydration and medication) from disabled infants with life-threatening conditions. The hospital must report the name of the individual so designated to this agency, which is responsible for administering this provision within the State of Oklahoma. The hospital administrator is assumed to be the contact person unless someone else is specifically designated.
(c) The Child Abuse Unit of the Oklahoma Child Welfare Unit is responsible for coordination and consultation with the individual designated. In turn, the hospital is responsible for prompt notification to the Child Abuse Unit of any case of suspected medical neglect or withholding of medically-indicated treatment from disabled infants with life-threatening conditions. This information must be communicated to Child Abuse Unit, Child Welfare Services, P.O. Box 25352, Oklahoma City, OK 73125, Telephone: (405) 521-2283. Should a report need to be made when the office is closed, telephone the statewide toll-free Child Abuse Hot Line: 1-800-522-3511.
(d) Each Hospital should provide the name, title and telephone number of the designated individual and return it to the OHCA. This information is updated annually as part of the contract renewal. Should the designation change before that time, OHCA should be furnished revised information.
(a) Payment is made only for abortions in those instances where
the abortion is necessary due to a physical disorder, injury or
illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, or where the pregnancy is the result of an act of rape or incest. SoonerCare coverage for abortions to terminate pregnancies that are the result of rape or incest are considered to be medically necessary services and federal financial participation is available specifically for these services.
(1) For abortions necessary due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed, the physician must certify in writing that the abortion is being performed due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed. The mother's name and address must be included in the certification and the certification must be signed and dated by the physician. The certification must be attached to the claim.
(2) For abortions in cases of rape or incest, there are two requirements for the payment of a claim. First, the patient must fully complete the Patient Certification For Medicaid Funded Abortion. Second, the patient must have made a police report or counselor's report of the rape or incest. In cases where an official report of the rape or incest is not available, the physician must certify in writing and provide documentation that in his or her professional opinion, the patient was unable, for physical or psychological reasons, to comply with the requirement. The statement explains the reason the rape or incest was not reported. The mother's name and address must be included in the certification and the certification must be signed and dated by the physician. In cases where a physician provides certification and documentation of a client's inability to file a report, the Authority will perform a prepayment review of all records to ensure there is sufficient documentation to support the physician's certification.
(b) The Oklahoma Health Care Authority performs a look-behind procedure for abortion claims paid from SoonerCare funds. This procedure will require that this Agency obtain the complete medical records for abortions paid under SoonerCare. On a post payment basis, this Authority will obtain the complete medical records on all claims paid for abortions.
(c) Claims for spontaneous abortions, including Dilation and Curettage do not require certification. The following situations also do not require certification:
(1) If the physician has not induced the abortion, counseled or otherwise collaborated in inducing the abortion, and
(2) If the process has irreversibly commenced at the point of the physician's medical intervention.
(d) Claims for the diagnosis incomplete abortion require medical review. The appropriate diagnosis codes should be used indicating spontaneous abortion, etc.; otherwise the procedure will be denied.
(a) Payment is made to hospitals for elective sterilizations performed in behalf of eligible individuals if all of the following circumstances are met:
(1) The patient must be at least 21 years of age at the time the consent form is signed,
(2) The patient must be mentally competent,
(3) A properly completed Federally mandated consent for sterilization form is attached to the claim, and
(4) The form is signed by the patient at least 30 days, but not more than 180 days prior to the surgery.
(b) When a sterilization procedure is performed in conjunction with a C-section, it is considered multiple surgery and a consent form for the sterilization is required.
(c) Reversal of sterilization procedures for the purposes of conception are not covered. Reversal of sterilization procedures may be covered when medically necessary and substantiating documentation is attached to the claim.
A hysterectomy performed for purposes of sterilization or family planning is not compensable. Payment is made to hospitals for therapeutic hysterectomies only when one of the following circumstances is met.
(1) A properly completed hysterectomy acknowledgement is attached to the claim form. The acknowledgement must clearly state that the patient or her representative was informed, orally and in writing, prior to the surgery that she would be rendered permanently incapable of reproduction. The 30 day waiting period which applies to elective sterilizations does not apply to therapeutic hysterectomies.
(2) The surgeon must certify in writing that the patient was sterile prior to the surgery. The reason for the sterility, i.e., post-menopausal, previous tubal ligation, etc. must be given.
(3) The surgeon must certify that the surgery was performed in an emergency, life endangering situation. The circumstances must be given. A hysterectomy acknowledgement form may be signed by the patient and dated after the surgery as long as the acknowledgement meets all other requirements. The patient must acknowledge in the form that prior to surgery she was advised orally and in writing that she would be rendered sterile as a result of the surgery.
The county Department of Human Services office where the mother resides must be notified in writing within five days of the child's birth in order for an individual person code to be assigned to the newborn. A claim may then be filed for nursery charges for the baby under the case number and the baby's name and assigned person code. Nursery charges billed on the mother's person code will be denied. Providers must use Form FSS-NB-1 to notify the county DHS office of the child's birth. Copies of the form may be obtained at the county DHS office.
|317:30-5-54.||Hospital rate appeals [REVOKED]|
|317:30-5-55.||Residential psychiatric treatment facility rate appeals [REVOKED]|
All inpatient services are subject to post-payment utilization review by the Oklahoma Health Care Authority, or its designated agent. These reviews will be based on OHCA's, or its designated agent's, admission criteria on severity of illness and intensity of treatment. In addition to the random sample of all admissions, retrospective review policy includes the following:
(1) Hospital stays less than three days in length will be reviewed for medical necessity and appropriateness of care. (Discharges involving healthy mother and healthy newborns may be excluded from this review requirement.) If it is determined that the inpatient stay was unnecessary or inappropriate, the prospective payment for the inpatient stay will be denied.
(2) Cases which indicate transfer from one acute care hospital to another will be monitored to help ensure that payment is not made for inappropriate transfers.
(3) Readmissions occurring within 30 days of prior acute care admission for a related condition will be reviewed to determine medical necessity and appropriateness of care or whether the readmission was potentially preventable. If it is determined that either or both admissions were unnecessary or inappropriate or potentially preventable, payment for either or both admissions may be denied. Such review may be focused to exempt certain cases at the sole discretion of the OHCA.
|317:30-5-57.||Notice of denial|
(a) General. It is the policy and intent to allow hospitals and physicians the opportunity to present any and all documentation available to support the medical necessity of an admission and/or extended stay of a SoonerCare member. If the OHCA, or its designated agent, upon their initial review determines the admission should be denied, a notice is sent to the facility and the attending physician(s) advising them of the decision. This notice also advises that a reconsideration request may be submitted within 60 days.
(b) Reconsideration request. All inpatient stays and outpatient observation services are subject to post-payment utilization review by the OHCA's designated Quality Improvement Organization (QIO). These reviews are based on severity of illness and intensity of treatment. It is the policy and intent of OHCA to allow hospitals and physicians the opportunity to present any and all documentation available to support the medical necessity of an admission and/or extended stay or outpatient observation of a SoonerCare member. If the QIO, upon their initial review determines the admission or outpatient observation services should be denied, a notice is issued to the facility and the attending physician advising them of the decision. This notice also advises that a reconsideration request may be submitted within the specified time frame on the notice and consistent with the Medicare guidelines. Additional information submitted with the reconsideration request is reviewed by the QIO that utilizes an independent physician advisor. If the denial decision is upheld through this review of additional information, the QIO sends written notification of the denial decision to the hospital, attending physician and the OHCA. Once the OHCA has been notified, the overpayment is processed as per the final denial determination.
(c) Reconsideration request not made. If the hospital or attending physician did not request reconsideration from the QIO, the QIO informs OHCA there has been no request for reconsideration and as a result their initial denial decision is final. OHCA, in turn, processes the overpayment as per the denial notice sent to the OHCA by the QIO.
(d) Patient liability. If an OHCA, or its designated agent, review results of a denial and the denial is upheld throughout the appeal process and refund from the hospital and physician is required, the member cannot be billed for the denied services.
(1) If a hospital or physician believes that an acute care hospital admission or continued stay is not medically necessary and thus not compensable but the member insists on treatment, the member should be informed in writing that he/she will be personally responsible for all charges.
(2) If a claim is filed and paid and the service is later denied the member is not responsible.
|317:30-5-58.||Supplemental Hospital Offset Payment Program|
The Supplemental Hospital Offset Payment Program (SHOPP) is a hospital assessment fee that is eligible for federal matching funds when used to reimburse SoonerCare services in accordance with Section 3241.1 of Title 63 of the Oklahoma Statutes.
The following words and terms, when used in this Section have the following meaning, unless the context clearly indicates otherwise:
means a hospital's fiscal year ending in 2009, as reported in the Medicare Cost Report or as determined by the Oklahoma Health Care Authority (OHCA) if the hospital's data is not included in a Medicare Cost Report.
means supplemental hospital offset assessment pursuant to Section 3241.1 of Title 63 of the Oklahoma Statutes.
means an institution licensed by the State Department of Health as a hospital pursuant to Section 1-701.1 of Title 63 of the Oklahoma Statutes maintained primarily for the diagnosis, treatment, or care of patients.
"Hospital Advisory Committee"
means the Committee established for the purposes of advising the OHCA and recommending provisions within and approval of any state plan amendment or waiver affecting the Supplemental Hospital Offset Payment Program.
"NET hospital patient revenue"
means the gross hospital revenue as reported on Worksheet G-2 (Columns 1 and 2, Lines "Total inpatient routine care services", Ancillary services", "Outpatient services") of the Medicare Cost Report, multiplied by hospital's ratio of total net to gross revenue, as reported on Worksheet G-3(Column 1, Line 3)"Net patient revenues") and Worksheet G-2 (Part I, Column 3, Line "Total patient revenues").
"Medicare Cost Report"
means the Hospital Cost Report, Form CMS-2552-96 or subsequent versions.
"Upper payment limit"
means the maximum ceiling imposed by 42 C F R
447.272 and 447.321 on hospital Medicaid reimbursement for inpatient and outpatient services, other than to hospitals owned or operated by state government.
"Upper payment limit gap"
means the difference between the upper payment limit and SoonerCare payments not financed using hospital assessments.
Supplemental Hospital Offset Payment Program.
Pursuant to 63 Okla. Stat.
3241.1 through 3241.6 the Oklahoma Health Care Authority (OHCA) is mandated to assess hospitals licensed in Oklahoma, unless exempted under (c) (2) of this Section, a supplemental hospital offset payment fee.
(2) The following hospitals are exempt from the SHOPP fee:
(A) a hospital that is owned or operated by the state or a state agency, or the federal government, as determined by OHCA, using most recent Medicare cost report worksheet S-2, column 1, line 18 or other line that indicates ownership, or by a federally recognized Indian tribe or Indian Health Services, as determined by OHCA, using the most recent IHS/Tribal facility list for Oklahoma as updated by the Indian Health Service Office of Resource Access and Partnerships in Partnership with the Centers for Medicaid and State operations.
(B) a hospital that provides more than fifty percent (50%) of its inpatient days under a contract with a state agency other than the OHCA, as determined by OHCA, using data provided by the hospital;
(C)a hospital for which the majority of its inpatient days are for any one of the following services, as determined by OHCA, using the Inpatient Discharge Data File published by the Oklahoma State Department of Health, or in the case of a hospital not included in the Inpatient Discharge Data File, using substantially equivalent data provided by the hospital:
(i) treatment of a neurological injury;
(ii) treatment of cancer;
(iii) treatment of cardiovascular disease;
(iv) obstetrical or childbirth services; or
(v) surgical care except that this exemption will not apply to any hospital located in a city of less than five hundred thousand (500,000) population and for which the majority of inpatient days are for back, neck, or spine surgery.
(D) a hospital that is certified by the Centers for Medicare and Medicaid Services (CMS) as a long term acute hospital, according to the most recent list of LTCH's published on the CMS http://www.cms.gov/LongTermCareHospitalPPS/08down load.asp or as a children's hospital; and
(E) a hospital that is certified by CMS as a critical access hospital, according to the most recent list published by Flex Monitoring Team for Critical Access Hospital (CAH) Information at http://www.flexmonitoring.org/cahlistRA.cgi, which is based on CMS quarterly reports, augmented by information provided by state Flex Coordinators.
The Supplemental Hospital Offset Payment Program Assessment.
(1) The SHOPP assessment is imposed on each hospital, except those exempted under (c) (2) of this Section, for each calendar year in an amount calculated as a percentage of each hospital's net hospital patient revenue. The assessment rate until December 31, 2012, is two and one-half percent (2.5%). At no time in subsequent years will the assessment rate exceed four percent (4%).
(2) OHCA will review and determine the amount of annual assessment in December of each year.
(3) A hospital may not charge any patient for any portion of the SHOPP assessment.
(4) The Method of collection is as follows:
(A) The OHCA will send a notice of assessment to each hospital informing the hospital of the assessment rate, the hospital's net hospital patient revenue calculation, and the assessment amount owed by the hospital for the applicable year.
(B) The hospital has thirty (30) days from the date of its receipt of a notice of assessment to review and verify the hospital's net patient revenue calculation, and the assessment amount.
(C) New hospitals will only be added at the beginning of each calendar year.
(D) The annual assessment imposed is due and payable on a quarterly basis. Each quarterly installment payment is due and payable by the fifteenth day of the first month of the applicable quarter (i.e. January 15th, April 15th, etc.)
(E) Failure to pay the amount by the 15th or failure to have the payment mailing postmarked by the 13th will result in a debt to the State of Oklahoma and is subject to penalties of 5% of the amount and interest of 1.25% per month.
(F) If a hospital fails to timely pay the full amount of a quarterly assessment, OHCA will add to the assessment:
(i) a penalty assessment equal to five percent (5%) of the quarterly amount not paid on or before the due date, and
(ii) on the last day of each quarter after the due date until the assessed amount and the penalty imposed under section (i) of this paragraph are paid in full, an additional five percent (5%) penalty assessment on any unpaid quarterly and unpaid penalty assessment amounts.
(iii) the quarterly assessment including applicable penalties and interest must be paid regardless of any appeals action requested by the facility. If a provider fails to pay the OHCA the assessment within the time frames noted on the invoice to the provider, the assessment, applicable penalty, and interest will be deducted from the facility's payment. Any change in payment amount resulting from an appeals decision in which a recoupment or additional allocation is necessary will be adjusted in future payments in accordance with OAC 317:2-1-15 SHOPP appeals.
(iv) If additional allocation or recoupment resulting from an appeal is for the current calendar year and another SHOPP payment is scheduled for the calendar year, an adjustment to the next payment will be calculated. If additional allocation or recoupment is for a prior calendar year, a separate payment/account receivable (AR) will be issued.
(G) The SHOPP assessments excluding penalties and interest are an allowable cost for cost reporting purposes.
Supplemental Hospital Offset Payment Program Cost Reports.
(1) The report referenced in paragraph (b)(6) must be signed by the preparer and by the Owner, authorized Corporate Officer or Administrator of the facility for verification and attestation that the reports were compiled in accordance with this section.
(2) The Owner or authorized Corporate Officer of the facility must retain full accountability for the report's accuracy and completeness regardless of report submission method.
(3) Penalties for false statements or misrepresentation made by or on behalf of the provider are provided at 42 U.S.C. Section 1320a-7b which states, in part,
"Whoever...(2) at any time knowingly and willfully makes or causes to be made any false statement of a material fact for use in determining rights to such benefits or payment...shall (i) in the case of such statement, representation, failure, or conversion by any person in connection with furnishing (by the person) of items or services for which payment is or may be under this title (42 U.S.C.
1320 et seq.), be guilty of a felony and upon conviction thereof fined not more than $25,000 or imprisoned for not more than five years or both, or (ii) in the case of such a statement, representation, concealment, failure or conversion by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $10,000 or imprisoned for not more than one year, or both."
(4) Net hospital patient revenue is determined using the data from each hospital's applicable Medicare Cost Report contained in the Centers for Medicare and Medicaid Services' Healthcare Cost Report Information System (HCRIS) file.
(A) Through 2013, the base year for assessment shall be the hospital's fiscal year that ended in 2009, as contained in the HCRIS file dated December 31, 2010;
(B) For years 2014 and 2015, the base year for assessment shall be the hospital's fiscal year that ended in 2012, as contained in the HCRIS file dated June 30, 2013; and
(C) For subsequent two-year periods the base year for assessment shall be the hospital's fiscal year that ended two years prior (e.g.,2016 & 2017
2014 fiscal year; 2018 & 2019
2016 fiscal year), as contained in the HCRIS file dated June 30 of the following year.
(5) If a hospital's applicable Medicare Cost Report is not contained in the Centers for Medicare and Medicaid Services' HCRIS file, the hospital will submit a copy of the hospital's applicable Medicare Cost Report to the Oklahoma Health Care Authority (OHCA) in order to allow the OHCA to determine the hospital's net hospital patient revenue for the base year.
(6) If a hospital commenced operations after the due date for a Medicare Cost Report, the hospital will submit its initial Medicare Cost Report to Oklahoma Health Care Authority (OHCA) in order to allow the OHCA to determine the hospital's net patient revenue for the base year.
(7) Partial year reports may be prorated for an annual basis. Hospitals whose assessments were based on partial year cost reports will be reassessed the following year using a cost report that contains a full year of operational data.
(8) In the event that a hospital does not file a uniform cost report under 42 U.S.C., Section 1396a(a)(40), the OHCA will provide a data collection sheet for such facility.
Closure, merger and new hospitals.
(1) If a hospital ceases to operate as a hospital or for any reason ceases to be subject to the fee, the assessment for the year in which the cessation occurs is adjusted by multiplying the annual assessment by a fraction, the numerator of which is the number of days in the year during which the hospital is subject to the assessment and denominator of which is 365. Within 30 days of ceasing to operate as a hospital, or otherwise ceasing to be subject to the assessment, the hospital will pay the assessment for the year as so adjusted, to the extent not previously paid.
(2) Cost reports required under (e)(5),(e)(6),or (e)(8) of this subsection for assessment calculation must be submitted to OHCA by September 30 of each year.
Disbursement of payment to hospitals.
(1) All in-state inpatient hospitals are eligible for hospital access payments each year as set forth in this subsection except for those listed in OAC 317:30-5-58 (c) (2):
(A) In addition to any other funds paid to inpatient critical access hospital for services provided to SoonerCare members, each critical access hospital will receive hospital access payments equal to the amount by which the payment for these services was less than one hundred one percent (101%) of the hospital's cost of providing these services.
(B) In addition to any other funds paid to hospitals for inpatient hospital services to SoonerCare members, each eligible hospital will receive inpatient hospital access payments each year equal to the hospital's pro rata share of the inpatient supplemental payment pool as reduced by payments distributed in paragraph (1) (A) of this Section. The pro rata share will be based upon the hospital's SoonerCare payment for inpatient services divided by the total SoonerCare payments for inpatient services of all eligible hospitals within each class of hospital and cannot exceed the UPL for the class.
(2) All in-state outpatient hospitals are eligible for hospital access payments each year as set forth in this subsection except for those listed in OAC 317:30-5-58 (c) (2):
(A) In addition to any other funds paid to outpatient critical access hospital for services provided to SoonerCare members, each critical access hospital will receive hospital access payments equal to the amount by which the payment for these services was less than one hundred one percent (101%) of the hospital's cost of providing these services.
(B) In addition to any other funds paid to hospitals for outpatient hospital services to SoonerCare members, each eligible hospital will receive outpatient hospital access payments each year equal to the hospital's pro rata share of the outpatient supplemental payment pool as reduced by payments distributed in paragraph (2) (A) of this Section. The pro rata share will be based upon the hospital's SoonerCare payment for outpatient services divided by the total SoonerCare payments for outpatient services of all eligible hospitals within each class of hospital and cannot exceed the UPL for the class.
(3) Medicaid payments to a group of facilities within approved categories may not exceed the upper payment limit in accordance with 42 CFR 447.272 (b) (2) and 42 CFR 447.321 (b) (2). If any audit determines that a class of hospitals has exceeded the inpatient and/or outpatient UPL the overpayment will be recouped and redistributed based on the following methods:
(A) If it is determined prior to issuance of hospital access payments that the pool of hospitals would exceed the upper payment limit estimate of that pool, the amount above the UPL estimate will be allocated to another pool of hospitals that does not exceed the upper payment limit estimate of that pool. The reallocation can be applied to multiple pools if necessary.
(B) If the overpayment cannot be redistributed due to all classes being paid at their UPL, the overpayment will be deposited in to the SHOPP fund.
(4) In order to ensure sufficient funds to make payments effective July 1, 2013 OHCA shall reduce the next quarterly payment by 1.4% (OHCA will pay out 23.6% of the assessment rather than 25%). This reduction will be distributed in the fourth quarter of the year as soon as all assessments are received. This payment will also be increased by penalties collected within the year as long as the penalties do not cause the payment to exceed the UPL estimate. If all assessments are received prior to the 4th quarterly payment being processed the 4th quarter may be adjusted to pay out 26.4% plus accrued penalties.
(5) Effective for all subsequent calendar years the OHCA will distribute payments in the following quarterly percentages: 23.6%, 25%, 25%, 25%. A 5th payment of 1.4% in the fourth quarter of each calendar year will also be made as soon as all assessments are received. This payment will also be increased by any penalties collected within the year as long as the penalties do not cause the payment to exceed the UPL estimate. If all assessments are received prior to the 4th quarterly payment being processed the 4th quarter payment may be adjusted to pay out 26.4% plus accrued penalties.