Current through Vol. 41, No. 20, July 1, 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
