Current through Vol. 42, No. 1, September 16, 2024
(a)
Encounters. Payment is made
for one (1) encounter per member per day. Encounters with more than one (1)
health professional and multiple encounters with the same health professional
that takes place on the same day and a single location, constitute a single
visit except when the member, after the first encounter, suffers illness or
injury requiring additional diagnosis or treatment. Medical review will be
required for additional visits for children. Payment is also limited to four
(4) visits per member per month for adults. This limit may be exceeded if the
SoonerCare Choice member has elected the RHC as his/her/their Patient Centered
Medical Home/Primary Care Provider. RHCs must bill the combined fees of all
"core" services provided during an encounter on the appropriate claim form.
Claims must include reasonable and customary charges.
(1)
RHC. The appropriate revenue
code is required. No HCPCS or CPT code is required.
(2)
Mental health. Mental health
services must include a revenue code and a HCPCS code.
(3)
Obstetrical care. The
appropriate revenue code and HCPCS code are required. The date the member is
first seen is required. The primary pregnancy diagnosis code is also required.
Secondary diagnosis codes are used to describe complications of pregnancy.
Delivery must be billed by the independent practitioner who has a contract with
the OHCA.
(4)
Family
planning. Family planning encounters require a revenue code, HCPCS code,
and a family planning diagnosis.
(5)
EPSDT screening. EPSDT
screenings must be billed by the attending provider using the appropriate
Preventative Medicine procedure code from the CPT Manual. Payment is made
directly to the RHC on an encounter basis for on-site dental services by a
licensed dentist for members under the age of twenty-one (21).
(6)
Dental. Dental services for
children must be billed on the appropriate dental claim form.
(A)
EPSDT dental screening. An
EPSDT dental screening includes oral examination, prophylaxis and fluoride
treatment, charting of needed treatment, and, if necessary, x-rays (including
two bite wing films). This service must be filed on claim form ADM-36-D for
EPSDT reporting purposes.
(B)
Dental encounter. A dental encounter consists of all dental
treatment other than a dental screening. This service must be billed on the
ADM-36-D.
(7)
Visual analysis. Visual analysis services for a child with
glasses, or a child who needs glasses, or a medical eye exam. This includes the
refraction and medical eye health evaluation. Visual analysis services are
billed using the appropriate revenue code and a HCPCS code. Payment is made
directly to the RHC on an encounter basis for on-site optometric services by a
licensed optometrist for members under the age of twenty-one (21).
(b)
Services billed
separately from encounters.
(1) Other
ambulatory services and preventive services itemized separately from encounters
must be billed using the appropriate revenue, HCPC and/or CPT codes. Claims
must include reasonable and customary charges from the physical location where
services were rendered/performed.
(A)
Laboratory. The RHC must be CLIA certified for specialized
laboratory services performed. Laboratory services must be itemized separately
using the appropriate CPT or HCPCS code.
(B)
Radiology. Radiology must be
identified using the appropriate CPT or HCPC code with the technical component
modifier. Radiology services are paid at the technical component rate. The
professional component is included in the encounter rate.
(C)
Immunizations. The
administration fee for immunizations provided on the same day as the EPSDT exam
is billed separately.
(D)
Contraceptives. Contraceptives are billed independently from the
family planning encounter. A revenue code and the appropriate CPT or HCPC codes
are required.
(E)
Eyeglasses. Eyeglasses prescribed by a licensed optometrist are
billed using the appropriate revenue code and HCPCS code. Payment is limited to
two eyeglasses per year. Any eyeglasses beyond this limit must be prior
authorized and determined to be medically necessary.
(2) Other ambulatory services provided
off-site by independent practitioners (through subcontracting agreements or
arrangements for services not available at the clinic) must be billed to the
SoonerCare program by the provider rendering the service. Independent
practitioners must meet provider eligibility criteria and must have a current
contract with the OHCA.
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 13 Ok Reg 397,
eff 11-14-95 (emergency); Amended at 13 Ok Reg 1645, eff 5-27-96 ; Amended at
16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 2368, eff 6-26-00
; Amended at 19 Ok Reg 2134, eff 6-27-02 ; Amended at 24 Ok Reg 895, eff
5-11-07 ; Amended at 26 Ok Reg 249, eff 1-1-09 (emergency); Amended at 26 Ok
Reg 1053, eff 5-11-09 ; Amended at 30 Ok Reg 1164, eff
7-1-13
