Current through Vol. 42, No. 1, September 16, 2024
(a)
Definitions. The following
words and terms, when used in this Section, have the following meaning, unless
the context clearly indicates otherwise.
(1)
"Assistive technology professional" or "ATP" means a
for-service provider who is involved in analysis of the needs and training of a
consumer in the use of a particular assistive technology device or is involved
in the sale and service of rehabilitation equipment or commercially available
assistive technology products and devices. All ATPs are required to be
credentialed by Rehabilitation Engineering and Assistive Technology Society of
North America (RESNA).
(2)
"Custom seating system" means a wheelchair seating system which is
individually made for a member using a plaster model of the member, a
computer-generated model of the member (e.g., CAD-CAM technology), or the
detailed measurements of the member to create either:
(A) A molded, contoured, or carved (foam or
other suitable material) custom-fabricated seating system that is incorporated
into the wheelchair base; or
(B) A
custom seating system made from multiple pre-fabricated components or a
combination of custom fabricated materials and pre-fabricated components which
have been configured and attached to the wheelchair base or incorporated into a
wheelchair seat and/or back in a manner that the wheelchair could not be easily
re-adapted for use by another individual.
(3)
"Specialty evaluation" means
the determination and documentation of the consumer's pathology, history and
prognosis, and the physiological, functional, and environmental factors that
impact the selection of an appropriate wheeled mobility system.
(b)
Medical
Necessity. Medical necessity, pursuant to Oklahoma Administrative Code
(OAC)
317:30-5-211.2,
is required for a wheelchair to be covered and reimbursed by SoonerCare. Only
one (1) wheelchair is covered as medically necessary during its reasonable
useful lifetime, unless the member's documented medical condition indicates the
current wheelchair no longer meets the member's medical need. Backup
wheelchairs are not covered items.
(c)
Prior authorization. Prior
authorization, pursuant to OAC
317:30-5-211.3,
is required for selected wheelchairs to be covered and reimbursed by
SoonerCare. All prior authorization requests for the purchase of a wheelchair
must indicate the length of the warranty period and what is covered under the
warranty.
(1) Wheelchairs, wheelchair parts
and accessories, and wheelchair modifications that are beneficial primarily in
allowing the member to perform leisure or recreational activities are not
considered medically necessary and will not be authorized.
(2) Wheelchair parts, accessories, and/or
modifications that are distinctly and separately requested and priced from the
original wheelchair request may require prior authorization.
(3) The Oklahoma Health Care Authority will
deny prior authorization requests when the required forms have not been fully
completed or the member's medical record does not provide sufficient
information to establish medical necessity or to determine that the criteria
for coverage has been met.
(d)
Coverage and limitations.
For members who reside in a long-term care facility or intermediate care
facility for individuals with intellectual disabilities, all standard manual
and power wheelchairs are considered part of the facility's per diem rate.
Repairs and maintenance for wheelchairs are considered part of the facility's
per diem rate.
(e)
Rental,
repairs, maintenance, and delivery. Refer to OAC
317:30-5-211.4
through
317:30-5-211.5.
(f)
Documentation.
(1) The specialty evaluation or wheelchair
selection documentation must be submitted with the prior authorization
request.
(2) The specialty
evaluation or wheelchair selection must be performed no longer than ninety (90)
days prior to the submission of the prior authorization request.
(3) The results of the specialty evaluation
or wheelchair selection documentation must be supported by the information
submitted on the member's medical record.
(4) A copy of the dated and signed written
specialty evaluation or wheelchair selection document must be maintained by the
wheelchair provider. The results of the specialty evaluation or wheelchair
selection must be written, signed, and dated by the medical professional who
evaluated the member or the ATP who was involved in the wheelchair selection
for the member.
Added at 27 Ok Reg
303, eff 1-1-10 (emergency); Added at 27 Ok Reg 1455, eff
6-11-10
