Okla. Admin. Code § 317:30-3-1 - [Effective9/14/2022]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.
Notes
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