Current through Vol. 42, No. 1, September 16, 2024
(a) School-based
services are medically necessary health-related and rehabilitative services
that are provided by a qualified school provider to a student under the age of
twenty-one (21) pursuant to an Individualized Education Program (IEP), in
accordance with the Individuals with Disabilities Education Act (IDEA). Payment
is made to qualified school providers for delivery of school-based services,
provided that such services are, among other things, medically necessary and
sufficiently supported by medical records and/or other documentation, as
explained below.
(b) An IEP and all
relevant supporting documentation, including, but not limited to, the
documentation required by Oklahoma Administrative Code (OAC) 317:30-5-1020(c),
below, serves as the plan of care for consideration of reimbursement for
school-based services. The plan of care must contain, among other things, the
signatures, including credentials, of the provider(s) and the direct care staff
delivering services under the supervision of the professional; as well as a
complete, signed, and current IEP which clearly establishes the type,
frequency, and duration of the service(s) to be provided, the specific place of
services if other than the school (e.g., field trip, home), and measurable
goals for each of the identified needs. Goals must be updated to reflect the
current therapy, evaluation, or service that is being provided and billed to
SoonerCare.
(1) Except for those services,
referenced in OAC
317:30-5-1023(b)(2)(H),
a plan of care that meets the requirements of OAC 317:30-5-1020(b), above,
shall serve as a prior medical authorization for the purpose of providing
medically necessary and appropriate school-based services to students.
(2) For the purposes of
occupational therapy services, and services for members with speech, hearing,
and language disorders, a plan of care that meets the requirements of OAC
317:30-5-1020(b), above, may also, in accordance with sections (§§)
725.2(H) and 888.4(C) of Title 59 of the Oklahoma Statutes (O.S.) serve as a
valid prescription or referral for an initial evaluation and any subsequent
services, as is required by Title 42 of Code of Federal Regulations (C.F.R.),
§ 440.110.
(3) Physical
therapy services, by contrast, shall require a signed and dated prescription
from the student's physician prior to that student's initial evaluation, in
accordance with OAC
317:30-5-291(1).
Prescriptions for school-based physical therapy must be reauthorized at least
annually, and documented within Oklahoma State Department of Education's (OSDE)
online IEP system, as set forth in subsection (c), below.
(c) Qualified school providers must ensure
that adequate documentation is maintained within the OSDE online IEP system in
order to substantiate that all school-based services billed to SoonerCare are
medically necessary and comply with applicable state and federal Medicaid law.
Such documentation shall include, among other things:
(1) Documentation establishing sufficient
notification to a member's parents and receipt of adequate, written consent
from them, prior to accessing a member's or parent's public benefits or
insurance for the first time, and annually thereafter, in accordance with
34 C.F.R. §
300.154;
(2) Any referral or prescription that is
required by state or federal law for the provision of school-based services, or
for the payment thereof, in whole or in part, from public funds, including, but
not limited to,
42
C.F.R. §
440.110. However, any
prescription or referral ordered by a physician or other licensed practitioner
of the healing arts who has, or whose immediate family member has, a financial
interest in the delivery of the underlying service in violation of Section
1395nn, Title 42 of United States Code shall not be valid, and services
provided thereto shall not be eligible for reimbursement by the Oklahoma Health
Care Authority (OHCA);
(3) An
annual evaluation located in or attached to the IEP that clearly demonstrates,
by means of the member's diagnosis and any other relevant supporting
information, that school-based services are medically necessary, in accordance
with OAC
317:30-3-1(f).
Evaluations completed solely for educational purposes are not compensable.
Evaluations must be completed annually and updated to accurately reflect the
student's current status. Any evaluation for medically necessary school-based
services, including but not limited to, hearing and speech services, physical
therapy, occupational therapy, and psychological therapy, must include the
following information:
(A) Documentation that
supports why the member was referred for evaluation;
(B) A diagnosis that clearly establishes and
supports the need for school-based services;
(C) A summary of the member's strengths,
needs, and interests;
(D) The
recommended interventions for identified needs, including outcomes and goals;
(E) The recommended units and
frequency of services; and
(F) A
dated signature and the credentials of the professional completing the
evaluation; and
(4)
Documentation that establishes the medical necessity of the school-based
services being provided between annual evaluations, including, for example,
professional notes or updates, reports, and/or assessments that are signed,
dated, and credentialed by the rendering practitioner.
(d) All claims related to school-based
services that are submitted to OHCA for reimbursement must include any numeric
identifier obtained from OSDE.
Added at 14 Ok Reg
3707, eff 8-1-97 (emergency); Added at 15 Ok Reg 1528, eff 5-11-98; Amended at
17 Ok Reg 2394, eff 6-26-00; Amended at 19 Ok Reg 2134, eff
6-27-02
