Current through Vol. 42, No. 1, September 16, 2024
(a)
Inpatient
behavioral health. Services are covered when provided in accordance with
a documented individualized service plan developed to treat the identified
behavioral health needs.
(1) Inpatient
psychiatric service providers must meet the requirements and applicable
limitations, restrictions, or prior authorization requirements set forth in
Oklahoma Administrative Code (OAC)
317:30-5-95 through
317:30-5-97.
(2) The provision of inpatient psychiatric
services by Indian Health Services (IHS) facilities are reimbursed at the OMB
inpatient encounter rate. Inpatient psychiatric services provided by non-IHS
facilities are reimbursed at the established per diem or DRG
rate.
(b)
Outpatient behavioral health. Services are covered when provided
in accordance with a documented individualized service plan developed to treat
the identified mental health needs and/or SUD. Outpatient behavioral health
services are reimbursed at the I/T/U outpatient encounter rate unless otherwise
noted in the section.
(1) A full description
of services may be found at OAC
317:30-5-241 and
317:30-5-241.5(d),
317:30-5-241.7. Services may
include, but are not limited to:
(A) Mental
health and/or substance use assessment/evaluation and testing;
(B) Service plan development;
(C) Crisis intervention services;
(D) Medication training and
support;
(F) Individual/interactive
psychotherapy;
(G) Group
psychotherapy;
(H) Family
psychotherapy;
(I)
Medication-assisted treatment (MAT) services and/or medication; and
(J) Peer recovery support specialist (PRSS)
services.
(2) In order to
support access to behavioral health services, these services may be provided in
settings outside of the I/T/U. Off site services must take place in a
confidential setting.
(3) For the
provision of behavioral health related case management services, I/T/U
facilities must be fully contracted with the Oklahoma Health Care Authority
(OHCA) as an outpatient behavioral health agency. The provision of these
services is considered to be outside of the I/T/U encounter and will be paid at
the current FFS rate. Contracted behavioral health case management providers
must comply with the requirements found at OAC
317:30-5-241.6 and are
responsible for obtaining all necessary prior authorizations, if
needed.
(4) For the provision of
psychosocial rehabilitation services, I/T/U facilities must be fully contracted
with the OHCA as an outpatient behavioral health agency. The provision of these
services is considered to be outside of the I/T/U encounter and will be paid at
the current FFS rate. Contracted psychosocial rehabilitation service providers
must comply with the requirements found at OAC
317:30-5-241.3 and are
responsible for obtaining all necessary prior authorizations, if
needed.
(5) Services provided by
behavioral health practitioners, such as, licensed clinical social workers
(LCSW), licensed marital and family therapists (LMFT), licensed professional
counselors (LPC), licensed behavioral health practitioners (LBHP), licensed
alcohol and drug counselors (LADC), and licensure candidates are not eligible
for direct reimbursement as practitioners. Services provided by the
aforementioned practitioners are compensable only when billed by their
OHCA-contracted employer and when provided in those clinical settings in which
they are currently approved to render services. Licensure candidates must meet
the requirements contained in OAC
317:30-5-240.3.
(6) Behavioral health services must be billed
on an appropriate claim form using the appropriate procedure code and
guidelines. The time indicated on the claim form must be the time actually
spent with the member.
(c)
Residential substance use disorder
(SUD). For the provision of residential SUD treatment services, I/T/U
facilities must be contracted as SoonerCare providers and meet the requirements
found at OAC
317:30-5-95.43 through
317:30-5-95.49. Residential SUD
treatment services will be reimbursed at the OMB outpatient encounter
rate.
Added at 23 Ok Reg
2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff
7-25-08
