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 317:30-5-218 - Reimbursement
Universal Citation: OK Admin Code 317:30-5-218
Current through Vol. 41, No. 20, July 1, 2024
(a) Medical supplies, equipment and appliances.
(1)
Reimbursement for medical supplies, equipment, and appliances will be made
using an amount derived from the lesser of the Oklahoma Health Care Authority
(OHCA) maximum allowable fee or the provider's usual and customary charge. The
maximum allowable fee is the maximum amount that the OHCA will pay a provider
for an allowable procedure. When a code is not assigned a maximum allowable fee
for a unit of service, a fee will be established.
(2) The fee schedule will be reviewed
annually. Adjustments to the fee schedule may be possible at any time based on
efficiency, budget considerations, federal regulations, and quality of care as
determined by the OHCA.
(3) Payment
for medical supplies, equipment, and appliances will be calculated using the
rate methodologies found in the Oklahoma Medicaid State Plan.
(4) Payment is not made for medical supplies,
equipment, and appliances that are not deemed as medically necessary or
considered over-the-counter.
(5)
OHCA does not reimburse medical supplies, equipment, and appliances providers
separately for services that are included as part of the payment for another
treatment program. For example, all items required during inpatient stays are
paid through the inpatient payment structure.
(6) Medical supplies, equipment, and
appliance products purchased at a pharmacy are paid the equivalent to Medicare
Part B, average sales price (ASP) + six percent (6%). When ASP is not
available, an equivalent price is calculated using wholesale acquisition cost
(WAC). If no Medicare, ASP, or WAC pricing is available, then the price will be
calculated based on invoice cost.
(b) Manually-priced medical equipment and supplies. There may be instances when manual pricing is required. When it is, the following pricing methods will be used:
(1)
Invoice pricing.
Reimbursement is at the provider's documented manufacturer's suggested retail
price (MSRP) minus thirty percent (30%) or at the provider's invoice cost plus
thirty percent (30%), whichever is the lesser of the two.
(2)
Fair market pricing. OHCA
may establish a fair market price through claims review and analysis. For a
list of medical equipment and supplies that are fair market-priced, refer to
the OHCA website at www.okhca.org for the
fair market value list (Selected medical supplies, equipment, and appliance
items priced at fair market price).
(c) Oxygen equipment and supplies.
(1) Payment for stationary
oxygen systems (liquid oxygen systems, gaseous oxygen systems, and oxygen
concentrators) is based on continuous rental, i.e., a continuous monthly
payment that is made as long as it is medically necessary. The rental payment
includes all contents and supplies, e.g., regulators, tubing, masks, etc.
Portable oxygen systems are considered continuous rental. Ownership of the
equipment remains with the supplier.
(2) Separate payment will not be made for
maintenance, servicing, delivery, or for the supplier to pick up the equipment
when it is no longer medically necessary. In addition, the provider/supplier
will not be reimbursed for mileage.
(3) Payment for oxygen and oxygen equipment
and supplies will not exceed the Medicare fee for the same procedure
code.
(4) For residents in a
long-term care facility, durable medical equipment products, including oxygen,
are included in the facility's per diem rate.
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 24 Ok Reg 2890, eff 7-1-07 (emergency); Amended at 25 Ok Reg 1161, eff 5-25-08; Amended at 27 Ok Reg 628, eff 14-13-10 (emergency); Amended at 27 Ok Reg 1451, eff 6-11-10
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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