Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 17 - MEDICAL SUPPLIERS
Section 317:30-5-211.2 - Medical necessity
Current through Vol. 41, No. 20, July 1, 2024
(a) Coverage. Coverage is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member, in accordance with state and federal Medicaid law, including, but not limited to, Oklahoma Administrative Code (OAC) 317:30-3-1(f). The member's diagnosis must warrant the type of equipment or supply being purchased or rented.Items that are used for the following are not a benefit to a member of any age:
(b) Ordering requirements. All medical supplies, equipment, and appliances as defined by 42 Code of Federal Regulations (C.F.R.) § 440.70(b)(3) and OAC 317:30-5-211.1, nursing services, and home health aide services provided by a home health agency, must be ordered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, working in accordance with State law, as part of a written plan of care.
(c) Prescription requirements. All medical supplies, equipment, and appliances, as those terms are defined by 42 C.F.R. § 440.120 and OAC 317:30-5-211.1, except for hearing aid batteries and equipment repairs with a cost per item of less than $1,000.00 total parts and labor, require a prescription signed by a physician, a physician assistant, or an advanced practice registered nurse. Except as otherwise stated in state or federal law, the prescription must be in writing, or given orally and later reduced to writing by the provider filling the order. Prescriptions are valid for no more than one (1) year from the date written. The prescription must include the following information:
(d) Certificate of medical necessity (CMN). For certain items or services, the supplier must receive a signed CMN/OHCA CMN from the treating physician, non-physician practitioner, or dentist. The supplier must have a signed CMN/OHCA CMN in their records before they submit a claim for payment. The CMN/OHCA CMN may be faxed copy, electronic copy, or the original hardcopy.
(e) Place of service.
(f) Contracting requirements. Per 42 C.F.R. 455.410(b), medical supplies, equipment, and appliances may only be ordered or prescribed by a SoonerCare contracted provider.
Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at 29 Ok Reg 473, eff 5-11-12