Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 104 - SCHOOL-BASED CASE MANAGEMENT SERVICES
Section 317:30-5-1031 - Coverage by category
Universal Citation: OK Admin Code 317:30-5-1031
Current through Vol. 42, No. 1, September 16, 2024
(a) Payment is made for case management services to children as set forth in this Section.
(1)
Description of case management
services. The target group for case management services is individuals
0-21 who are receiving services pursuant to an Individualized Education Program
(IEP), an Individualized Family Service Plan (IFSP), a Section 504
Accommodation Plan, or an Individualized Health Service Plan (IHSP), and who
have a disability or are medically at risk. A disability is defined as a
physical or mental impairment that substantially limits one or more major life
activities. Medically at risk refers to individuals who have a diagnosable
physical or mental condition that has a high probability of impairing
cognitive, emotional, neurological, social or physical development.
(A) Services are provided to assist the
target population in gaining access to needed medical, social, educational, and
other services. Major components of the service include:
(i) Individualized needs assessment
(ii) Needs-based service planning;
(iii) Service coordination, monitoring and
advocacy;
(iv) Services plan
review; and
(v) Crisis assistance
planning.
(B) Case
record documentation of the service components listed in (1) of this subsection
is included as a case management activity. The client has the right to refuse
case management and cannot be restricted from services because of a refusal for
Case Management Services.
(C) Case
management does not include:
(i) Program
activities of the agency itself that do not meet the definition of case
management.
(ii) Administrative
activities necessary for the operation of the agency providing case management
services other than the overhead costs directly attributable to targeted case
management.
(iii) Diagnostic,
treatment or instructional services, including academic testing.
(iv) Services that are an integral part of
another service already reimbursed by SoonerCare.
(v) Activities that are an essential part of
SoonerCare administration, such as outreach, intake processing, eligibility
determination or claims processing.
(2)
Non-duplication of services.
To the extent any eligible members in the identified targeted population are
receiving TCM services from another provider agency as a result of being
members of other covered targeted groups, the providers assures that case
management activities are coordinated to avoid unnecessary duplication of
service. To the extent any of the services required by the member are a
SoonerCare covered benefit of a managed care organization of which the client
is a member, the provider will assure that timely referrals are made and that
coordination of care occurs.
(3)
Providers. Case management services must be provided by the
schools or their contractors.
(b) Individuals eligible for Part B of Medicare. Case Management Services provided to Medicare eligible members are filed directly with the fiscal agent.
Added at 16 Ok Reg 1927, eff 6-11-99; Amended at 19 Ok Reg 63, eff 9-1-01 (emergency); Amended at 19 Ok Reg 2127, eff 6-27-02
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