Current through Vol. 42, No. 1, September 16, 2024
(a)
Enhanced services. Enhanced
services are available for pregnant women eligible for SoonerCare and are in
addition to services for uncomplicated maternity cases. Women deemed high risk
based on criteria established by the Oklahoma Health Care Authority (OHCA) must
receive prior authorization for medically necessary enhanced benefits which
include:
(1) Prenatal at risk antepartum
management;
(2) A combined maximum
of five (5) fetal non stress test(s) and biophysical profiles (additional units
can be prior authorized for multiple fetuses) with one (1) test per week
beginning at thirty-two (32) weeks gestation and continuing to thirty-eight
(38) weeks; and
(3) A maximum of
three (3) follow-up ultrasounds not covered under Oklahoma Adminisrative Code
(OAC)
317:30-5-22(b)(2).
(b)
Prior
authorization. To receive enhanced services, the following documentation
must be received by the OHCA Medical Authorization Unit for review and
approval:
(1) A comprehensive prenatal
assessment from the American College of Obstetricians and Gynecologist (ACOG)
or other comparable comprehensive prenatal assessment; and
(2) Appropriate documentation supporting
medical necessity from a board eligible/board certified Maternal Fetal Medicine
(MFM) specialist, a board eligible/board certified Obstetrician-Gynecologist
(OB-GYN), or a board eligible/board certified Family Practice Physician who has
completed an Accreditation Council for Graduate Medical Education (ACGME)
approved residency. The medical residency program must include appropriate
obstetric training, and the physician must be credentialed by the hospital at
which they provide obstetrical services in order to perform such services. The
documentation must include information identifying and detailing the qualifying
high risk condition. Non-MFM obstetrical providers requesting enhanced services
are limited to a specific set of diagnoses as outlined on the OHCA website
(
www.okhca.org).
(c)
Reimbursement. When prior
authorized, enhanced benefits will be reimbursed as follows:
(1) Antepartum management for high risk is
reimbursed to the primary obstetrical provider. If the primary provider of
obstetrical care is not the MFM and wishes to request authorization of the
antepartum management fee, the treatment plan must be signed by the primary
provider of OB care. Additionally, reimbursement for enhanced at risk
antepartum management is not made during an in-patient hospital stay.
(2) Non stress tests, biophysical
profiles and ultrasounds [in addition to those covered under OAC
317:30-5-22(b)(2)
(A) through (C) ] are reimbursed when prior authorized.
(3) Reimbursement for enhanced at risk
antepartum management is not available to physicians who already qualify for
enhanced reimbursement as state employed physicians.
Added at 25 Ok Reg
426, eff 11-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at
26 Ok Reg 100, eff 8-1-08 (emergency); Amended at 26 Ok Reg 1063, eff
5-11-09
