(1) Coverage includes, but is
not limited to, the following medically necessary services:
(A) Inpatient hospital visits for all
SoonerCare covered stays. All inpatient services are subject to post-payment
review by the OHCA, or its designated agent.
(B) Inpatient psychotherapy by a
physician.
(C) Inpatient
psychological testing by a physician.
(D) One (1) inpatient visit per day, per
physician.
(E) Certain surgical
procedures performed in a Medicare certified free-standing ambulatory surgery
center (ASC) or a Medicare certified hospital that offers outpatient surgical
services.
(F) Therapeutic radiology
or chemotherapy on an outpatient basis without limitation to the number of
treatments per month for members with proven malignancies.
(G) Physician services on an outpatient basis
include:
(i) A maximum of four (4) visits per
member per month, including primary care or specialty, with the exception of
SoonerCare Choice members.
(ii)
Additional visits are allowed per month for treatment related to emergency
medical conditions and family planning services.
(H) Direct physician services in a nursing
facility.
(i) A maximum of two (2) nursing
facility visits per month are allowed; and if the visit(s) is for psychiatric
services, it must be provided by a psychiatrist or a physician with appropriate
behavioral health training.
(ii) To
receive payment for a second nursing facility visit in a month denied by
Medicare for aMedicare/SoonerCare member, attach the explanation of Medicare
benefits (EOMB) showing denial and mark "carrier denied
coverage."
(I) Diagnostic
x-ray and laboratory services.
(J)
Mammography screening and additional follow-up mammograms as per current
guidelines.
(K) Obstetrical
care.
(L) Pacemakers and prostheses
inserted during the course of a surgical procedure.
(M) Prior authorized examinations for the
purpose of determining medical eligibility for programs administered by OHCA. A
copy of the authorization, Oklahoma Department of Human Services (OKDHS) form
08MA016E, Authorization for Examination and Billing, must accompany the
claim.
(N) If a physician renders
direct care to a member on the same day as a dialysis treatment, payment is
allowed for a separately identifiable service unrelated to the
dialysis.
(O) Family planning
includes sterilization procedures for legally competent members twenty-one (21)
years of age and over who voluntarily request such a procedure and execute the
federally mandated consent form with his/her physician. A copy of the consent
form must be attached to the claim form. Separate payment is allowed for the
insertion and/or implantation of contraceptive devices during an office visit.
Certain family planning products may be obtained through the Vendor Drug
Program. Reversal of sterilization procedures for the purposes of conception is
not allowed. Reversal of sterilization procedures are allowed when medically
indicated and substantiating documentation is attached to the claim.
(P) Genetic counseling.
(Q) Laboratory testing.
(R) Payment for ultrasounds for pregnant
women as specified in Oklahoma Administrative Code (OAC)
317:30-5-22.
(S) Payment to the attending physician in a
teaching medical facility for compensable services when the physician signs as
claimant and renders personal and identifiable services to the member in
conformity with federal regulations.
(T) Payment to the attending physician for
the services of a currently Oklahoma licensed physician in training when the
following conditions are met:
(i) Attending
physician performs chart review and signs off on the billed
encounter;
(ii) Attending physician
is present in the clinic/or hospital setting and available for consultation;
and
(iii) Documentation of written
policy and applicable training of physicians in the training program regarding
when to seek the consultation of the attending physician.
(U) Payment for services rendered by medical
residents in an outpatient academic setting when the following conditions are
met:
(i) The resident has obtained a medical
license or a special license for training from the appropriate regulatory state
medical board; and
(ii) Has the
appropriate contract on file with the OHCA to render services within the scope
of their licensure.
(V)
The payment to a physician for medically directing the services of a certified
registered nurse anesthetist (CRNA) or for the direct supervision of the
services of an anesthesiologist assistant (AA) is limited. The maximum
allowable fee for the services of both providers combined is limited to the
maximum allowable had the service been performed solely by the
anesthesiologist.
(W) Screening and
follow up pap smears as per current guidelines.
(X) Medically necessary organ and tissue
transplantation services for children and adults are covered services based
upon the conditions listed in (i)-(v) of this subparagraph:
(i) All transplantation services, except
kidney and cornea, must be prior authorized;
(ii) All transplant procedures are reviewed
and prior authorization is based upon appropriate medical criteria;
(iii) All organ transplants must be performed
at a Medicare-approved transplantation center;
(iv) Procedures considered experimental or
investigational are not covered. For more information regarding experimental or
investigational including clinical trials, see OAC
317:30-3-57.1; and
(v) Donor search and procurement services are
covered for transplants consistent with the methods used by the Medicare
program for organ acquisition costs.
(Y) Donor expenses incurred for complications
are covered only if they are directly and immediately attributable to the
donation procedure. Donor expenses that occur after the ninety (90) day global
reimbursement period must be submitted to the OHCA for review.
(Z) Total parenteral nutritional (TPN)
therapy for identified diagnoses and when prior authorized.
(AA) Ventilator equipment.
(BB) Home dialysis equipment and
supplies.
(CC) Ambulatory services
for treatment of members with tuberculosis (TB). This includes, but is not
limited to, physician visits, outpatient hospital services, rural health clinic
visits and prescriptions. Drugs prescribed for the treatment of TB beyond the
prescriptions covered under SoonerCare require prior authorization by the
University of Oklahoma College of Pharmacy Help Desk using form "Petition for
TB Related Therapy." Ambulatory services to members infected with TB are not
limited to the scope of the SoonerCare program, but require prior authorization
when the scope is exceeded.
(DD)
Smoking and tobacco use cessation counseling for treatment of members using
tobacco.
(i) Smoking and tobacco use
cessation counseling consists of the 5As:
(I)
Asking the member to describe their smoking use;
(II) Advising the member to quit;
(III) Assessing the willingness of the member
to quit;
(IV) Assisting the member
with referrals and plans to quit; and
(V) Arranging for follow-up.
(ii) Up to eight (8) sessions are
covered per year per individual.
(iii) Smoking and tobacco use cessation
counseling is a covered service when performed by physicians, physician
assistants (PA), advanced registered nurse practitioners (ARNP), certified
nurse midwives (CNM), dentists, Oklahoma State Health Department (OSDH) and
Federally Qualified Health Center (FQHC) nursing staff, and maternal/child
health licensed clinical social worker trained as a certified tobacco treatment
specialist (CTTS). It is reimbursed in addition to any other appropriate global
payments for obstetrical care, primary care provider (PCP) care coordination
payments, evaluation and management codes, or other appropriate services
rendered. It must be a significant, separately identifiable service, unique
from any other service provided on the same day.
(iv) Chart documentation must include a
separate note that addresses the 5A's and office note signature along with the
member specific information addressed in the five (5) steps and the time spent
by the practitioner performing the counseling. Anything under three (3) minutes
is considered part of a routine visit and not separately billable.
(EE) Immunizations as specified by
the Advisory Committee on Immunization Practices (ACIP) guidelines.
(FF) Genetic testing and other molecular
pathology services are covered when medically necessary. Genetic testing may be
considered medically necessary when the following conditions are met:
(i) The member displays clinical features of
a suspected genetic condition, is at direct risk of inheriting the genetic
condition in question (e.g., a causative familial variant has been identified)
or has been diagnosed with a condition where identification of specific genetic
changes will impact treatment or management; and
(ii) Clinical studies published in
peer-reviewed literature have established strong evidence that the result of
the test will positively impact the clinical decision-making or clinical
outcome for the member; and
(iii)
The testing method is proven to be scientifically valid for the identification
of a specific genetically-linked inheritable disease or clinically important
molecular marker; and
(iv) A
medical geneticist, physician, or licensed genetic counselor provides
documentation that supports the recommendation for testing based on a review of
risk factors, clinical scenario, and family history.
(GG) Behavioral Health Integration Services.
For full guidelines, please refer to
www.okhca.org/mau.
(2) General coverage exclusions include, but
is not limited to, the following:
(A)
Inpatient admission for diagnostic studies that could be performed on an
outpatient basis.
(B) Services or
any expense incurred for cosmetic surgery.
(C) Services of two (2) physicians for the
same type of service to the same member on the same day, except when
supplemental skills are required and different specialties are
involved.
(D) Routine eye
examinations for the sole purpose of prescribing glasses or visual aids,
determination of refractive state, treatment of refractive errors or purchase
of lenses, frames or visual aids.
(E) Pre-operative care within twenty-four
(24) hours of the day of admission for surgery and routine post-operative care
as defined under the global surgery guidelines promulgated by Current
Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services
(CMS).
(F) Payment to the same
physician for both an outpatient visit and admission to hospital on the same
date.
(G) Sterilization of members
who are under twenty-one (21) years of age, mentally incompetent, or
institutionalized or reversal of sterilization procedures for the purposes of
conception.
(H) Non-therapeutic
hysterectomies.
(I) Medical
services considered experimental or investigational. For more information
regarding experimental or investigational including clinical trials, see OAC
317:30-3-57.1.
(J) Payment for more than four (4) outpatient
visits per member (home or office) per month, except visits in connection with
family planning, services related to emergency medical conditions, or primary
care services provided to SoonerCare Choice members.
(K) Payment for more than two (2) nursing
facility visits per month.
(L) More
than one (1) inpatient visit per day per physician.
(M) Physician services which are
administrative in nature and not a direct service to the member including such
items as quality assurance, utilization review, treatment staffing, tumor board
review or multidisciplinary opinion, dictation, and similar
functions.
(N) Charges for
completion of insurance forms, abstracts, narrative reports or telephone
calls.
(O) Payment for the services
of social workers, licensed family counselors, registered nurses or other
ancillary staff, except as specifically set out in OHCA rules.
(P) Induced abortions, except when certified
in writing by a physician that the abortion was 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, or that the pregnancy is the
result of an act of rape or incest. (Refer to OAC
317:30-5-6 or
317:30-5-50).
(Q) Speech and hearing services.
(R) Mileage.
(S) A routine hospital visit on the date of
discharge unless the member expired.
(T) Direct payment to perfusionist as this is
considered part of the hospital reimbursement.
(U) Inpatient chemical dependency
treatment.
(V) Fertility
treatment.
(W) Payment for removal
of benign skin lesions.