Current through Vol. 41, No. 20, July 1, 2024
(a) I/T/U
outpatient encounters that are billed to the OHCA must meet the definition in
this Section and are limited to services covered by the OHCA. These services
include health services included in the State Plan under Title XIX or Title XXI
of the Social Security Act.
(1) An I/T/U
encounter means a face to face or telehealth contact between a health care
professional and an IHS eligible SoonerCare member for the provision of
medically necessary Title XIX or Title XXI covered services through an IHS or
Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at
midnight, as documented in the patient's record.
(2) An I/T/U outpatient encounter means
outpatient services that may be covered when furnished to a patient by a
contracted SoonerCare provider employed by the I/T/U facility and rendered at
the I/T/U facility or other location, including the patient's place of
residence.
(b) The
following services may be considered reimbursable encounters subject to the
limitations of the Oklahoma State Plan and include any related medical supplies
provided during the course of the encounter:
(1) Medical;
(2) Diagnostic;
(3) Behavioral Health services [refer to OAC
317:30-5-1094
];
(4) Dental, Medical and Mental
Health Screenings;
(5) Vision;
(6) Physical Therapy;
(7) Occupational Therapy;
(8) Podiatry;
(9) Speech;
(10) Hearing;
(11) Visiting Nurse Service [refer to OAC
317:30-5-1093
];
(12) Smoking and Tobacco Use
Cessation Counseling ;
(13) Other
Title XIX or XXI services as allowed under OHCA's SoonerCare State Plan and
OHCA Administrative Rules;
(14)
Drugs or medication treatments provided during a clinic visit are part of the
encounter rate. For example, a member has come into the clinic with high blood
pressure and is treated at the clinic with a hypertensive drug or drug sample.
Drug samples are included in the encounter rate. Prescription drugs are
reimbursed pursuant to OAC
317:30-5-78(b)(4)(B).
(15) Encounters with a registered
professional nurse or a licensed practical nurse and related medical supplies
(other than drugs and biologicals) furnished on a part-time or intermittent
basis to home-bound members; and
(16) I/T/U Multiple Outpatient Encounters.
(A) OHCA will cover one medically necessary
outpatient medical encounter per member per day unless if due to an emergency,
the same member returns on the same day for a second visit with a different
diagnosis. Then, a second encounter is allowed.
(B) OHCA will cover one dental encounter per
member per day regardless of how many procedures are done or how many providers
are seen unless if due to an emergency, the same member returns on the same day
for a second visit and has a different diagnosis. Then, a second encounter is
allowed.
(C) OHCA will cover one
behavioral health professional outpatient encounter per member per day unless
if due to an emergency, the same member returns on the same day for a second
visit and has a different diagnosis. Then, a second encounter is allowed.
(D) Each service must have
distinctly different diagnoses in order to meet the criteria for multiple I/T/U
outpatient encounters.
(c) More than one outpatient visit with a
medical professional within a 24-hour period for distinctly different diagnoses
may be reported as two encounters. This does not imply that if a member is seen
at a single office visit with multiple problems that multiple encounters can be
billed. For example, a member comes to the clinic in the morning for an
immunization, and in the afternoon, the member falls and breaks an arm. This
would be considered multiple medical encounters and can be billed as two
encounters. However, a member who comes to the I/T/U facility for a diabetic
wellness screening and is then referred to a podiatrist within the clinic for
diabetes-related follow-up on the same date of service would not be considered
a distinctly different diagnosis and can only be billed as a single encounter.
(d) The following services may be
considered as separate or multiple encounters when two or more services are
provided on the same date of service with distinctly different diagnoses:
(1) Medical Services;
(2) Dental Services;
(3) Mental Health and addiction services with
similar diagnoses can only be billed as one encounter. In addition, if the
member is also seen for a medical office visit with a mental health or
addiction diagnosis, then it is considered a single encounter;
(4) Physical or occupational therapy (PT/OT).
If this service is also performed on the same date of service as the medical
encounter that determined the need for PT/OT (initial referral), then it is
considered a single encounter;
(5)
Administration of immunizations. If no other medical office visit occurs on the
same date of services; and
(6)
Tobacco cessation limited to state plan services. If no other medical or
addiction encounter occurs on the same date of service.
(e) I/T/U outpatient encounters for IHS
eligible SoonerCare members whether medical, dental, or behavioral health, are
not subject to prior authorization. Other State Plan covered services that the
I/T/U facility chooses to provide but which are not part of the I/T/U encounter
are subject to all applicable SoonerCare regulations which govern the provision
and coverage for that service.
Added at 23 Ok Reg
2575, eff 6-25-06; Amended at 25 Ok Reg 2698, eff 7-25-08; Amended at 28 Ok Reg
16, eff 8-13-10 (emergency); Amended at 28 Ok Reg 1435, eff
6-25-11
