Okla. Admin. Code § 317:35-17-22 - Billing procedures for ADvantage services
(a) Billing procedures for long-term care
medical services are contained in the Oklahoma Medicaid Management Information
Systems (OKMMIS) Billing and Procedure Manual. Questions regarding billing
procedures that cannot be resolved through a study of the manual are referred
to the Oklahoma Health Care Authority (OHCA).
(b) The Oklahoma Department of Human Services
OKDHS Aging Services (AS) approved ADvantage service plan is the basis for the
Medicaid Management Information Systems service prior authorization, specifying
the:
(1) Service;
(2) Service provider;
(3) Units authorized; and
(4) Begin- and end-dates of service
authorization.
(c) As
part of ADvantage quality assurance, provider audits are used to evaluate if
paid claims are consistent with service plan authorizations and documentation
of service provision. Evidence of paid claims not supported by service plan
authorization and/or documentation of service provision are turned over to the
OHCA Clinical Provider Audits Unit for follow-up investigation.
(d) All contracted providers for ADvantage
Waiver services must submit billing to the OHCA, Soonercare using the
appropriate designated software, or web-based solution for all claims
transactions. When the designated system is unavailable, contracted providers
submit billing directly to OHCA.
(e) Service time of personal care, case
management, nursing, advanced supportive/restorative assistance, in-home
respite, consumer-directed personal assistance services and supports, personal
services assistance, and advanced personal services assistance is documented
through the designated statewide Electronic Visit Verification System (EVV)
when provided in the home. Providers are required to use the EVV system. Refer
to OAC 317:30-3-34(7) for additional procedures for EVV system failure or EVV
system unavailability.
(f) The
provider must document the amount of time spent for each service, per Oklahoma
Administrative Code (OAC)
317:30-5-763.
For service codes that specify a time segment in their description, such as
fifteen (15) minutes, each timed segment equals one (1) unit. Only time spent
fulfilling the service for which the provider is authorized, per OAC
317:30-5-763
is authorized for time-based services. Providers do not bill for a unit of time
when not more than one-half of a timed unit is performed, such as, when a unit
is defined as fifteen (15) minutes, providers do not bill for services
performed for less than eight (8) minutes. The rounding rules utilized by the
EVV and web-based billing system to calculate the billable unit-amount of care,
services provided for duration of:
(1) Less
than eight (8) minutes cannot be rounded up and do not constitute a billable
fifteen (15) minute unit; and
(2)
Eight (8) to fifteen (15) minutes are rounded up and do constitute a billable
fifteen (15) minute unit.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(a) Billing procedures for long-term care medical services are contained in the Oklahoma Medicaid Management Information Systems (OKMMIS) Billing and Procedure Manual. Questions regarding billing procedures that cannot be resolved through a study of the manual are referred to the Oklahoma Health Care Authority (OHCA ).
(b) The Oklahoma Department of Human Services OKDHS Aging Services (AS) approved ADvantage service plan is the basis for the Medicaid Management Information Systems service prior authorization, specifying the:
(1) Service;
(2) Service provider;
(3) Units authorized; and
(4) Begin- and end-dates of service authorization.
(c) As part of ADvantage quality assurance, provider audits are used to evaluate if paid claims are consistent with service plan authorizations and documentation of service provision. Evidence of paid claims not supported by service plan authorization and/or documentation of service provision are turned over to the OHCA Clinical Provider Audits Unit for follow-up investigation.
(d) All contracted providers for ADvantage Waiver services must submit billing to the OHCA , Soonercare using the appropriate designated software, or web-based solution for all claims transactions. When the designated system is unavailable, contracted providers submit billing directly to OHCA .
(e) Service time of personal care, case management , nursing, advanced supportive/restorative assistance, in-home respite, consumer-directed personal assistance services and supports, personal services assistance, and advanced personal services assistance is documented through the designated statewide Electronic Visit Verification System (EVV) when provided in the home. Providers are required to use the EVV system. Refer to OAC 317:30-3-34(7) for additional procedures for EVV system failure or EVV system unavailability.
(f) The provider must document the amount of time spent for each service, per Oklahoma Administrative Code (OAC) 317:30-5-763. For service codes that specify a time segment in their description, such as fifteen (15) minutes, each timed segment equals one (1) unit. Only time spent fulfilling the service for which the provider is authorized, per OAC 317:30-5-763 is authorized for time-based services. Providers do not bill for a unit of time when not more than one-half of a timed unit is performed, such as, when a unit is defined as fifteen (15) minutes, providers do not bill for services performed for less than eight (8) minutes. The rounding rules utilized by the EVV and web-based billing system to calculate the billable unit-amount of care, services provided for duration of:
(1) Less than eight (8) minutes cannot be rounded up and do not constitute a billable fifteen (15) minute unit; and
(2) Eight (8) to fifteen (15) minutes are rounded up and do constitute a billable fifteen (15) minute unit.