Current through Vol. 42, No. 1, September 16, 2024
(a)
General. PA is the electronic or written authorization issued by
the Oklahoma Health Care Authority (OHCA) to a provider prior to the provision
of a service. Providers should obtain a PA before providing services.
(b)
Requirements. Billing must
follow correct coding guidelines as promulgated by the Centers for Medicare and
Medicaid Services (CMS) or per uniquely and publicly promulgated OHCA
guidelines. Medical supplies, equipment, and appliances claims must include the
most appropriate Healthcare Common Procedure Coding System (HCPCS) code as
assigned by the Medicare Pricing, Data, Analysis, and Coding (PDAC) or its
successor. Authorizations for services not properly coded will be denied. The
following services require PA:
(1) Services
that exceed quantity/frequency limits;
(2) Medical need for an item that is beyond
OHCA's standards of coverage;
(3)
Use of a Not Otherwise Classified (NOC) code or miscellaneous codes;
(4) Services for which a less costly
alternative may exist; and
(5)
Procedures indicating that a PA is required on the OHCA fee schedule.
(c)
PA requests.
(1)
PA requirements.
Requirements vary for different types of services. Providers should refer to
the service-specific sections of policy or the OHCA website for services
requiring a PA. Also refer to OAC
317:30-3-31.
(A)
Required forms. All required
forms are available on the OHCA website.
(B)
Certificate of medical necessity
(CMN). The prescribing physician, non-physician practitioner (NPP), or
dentist must complete the medical necessity section of the CMN. This section
cannot be completed by the supplier. The medical necessity section can be
completed by any health care clinician; however, only the member's physician,
NPP, or dentist may sign the CMN. By signing the CMN, the physician, NPP, or
dentist is validating the completeness and accuracy of the medical necessity
section. The member's medical records must contain documentation substantiating
that the member's condition meets the coverage criteria and the answers given
in the medical necessity section of the CMN. These records may be requested by
OHCA or its representatives to confirm concurrence between the medical records
and the information submitted with the PA request.
(2)
Submitting PA requests.
Contact information for submitting PA requests may be found in the OHCA
Provider Billing and Procedures Manual. An electronic version of this manual is
located on the OHCA website.
(3)
PA review. Upon verifying the completeness and accuracy of
clerical items, the PA request is reviewed by OHCA staff to evaluate whether or
not each service being requested meets SoonerCare's definition of "medical
necessity" [see OAC
317:30-3-1(f)]
as well as other criteria.
(4)
PA decisions. After the PA request is processed, a notice will be
issued regarding the outcome of the review.
(5)
PA does not guarantee
reimbursement. Provider status, member eligibility, and medical status
on the date of service, as well as all other SoonerCare requirements, must be
met before the claim is reimbursed.
(6)
PA of manually-priced items.
Manually-priced items must be prior authorized. For reimbursement of manually
priced items, see OAC
317:30-5-218.
Added at 24 Ok Reg
2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
5-25-08
