Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES
Section 317:30-5-96.3 - Methods of payment
Universal Citation: OK Admin Code 317:30-5-96.3
Current through Vol. 42, No. 1, September 16, 2024
(a) Reimbursement.
(1) Covered
inpatient psychiatric chemical dependency detoxification/withdrawal management
services will be reimbursed using one (1) of the following methodologies:
(A) Diagnosis related group (DRG);
(B) Cost-based; or
(C) A predetermined per diem payment.
(2) For members
twenty-one (21) to sixty-four (64) years of age, payment shall not be made for
any inpatient psychiatric episodes over sixty (60) days in a facility that
qualifies as an IMD.
(b) Levels of care.
(1)
Acute.
(A) Payment will be made
to psychiatric units within general medical surgical hospitals and critical
access hospitals utilizing a DRG methodology. [See OAC
317:30-5-41]
. Psychiatric professional (physicians and psychologists) services provided in
conjunction with the inpatient stay are separately payable from the DRG paid to
the hospital;
(B) Payment will be
made to psychiatric hospitals utilizing a predetermined statewide per diem
payment for all facility services provided during the inpatient stay.
Psychiatric professional (physicians and psychologists) services provided in
conjunction with the inpatient stay are separately payable from the per diem
paid to the hospital. Rates vary for public and private providers.
(2)
Acute II.
(A) Payment will be made to in-state
psychiatric hospitals or inpatient psychiatric programs utilizing a
predetermined all-inclusive per diem payment for routine, ancillary, and
professional services.
(B) Public
facilities will be reimbursed using either the statewide or facility-specific
interim rates and settled to total allowable costs as determined by analyses of
the cost reports (Form CMS 2552) filed with the OHCA.
(3)
PRTFs.
(A) A pre-determined per diem payment will be
made to private PRTFs with sixteen (16) beds or less for routine services. All
other services are separately billable.
(B) A predetermined all-inclusive per diem
payment will be made for routine, ancillary, and professional services to
private facilities with more than sixteen (16) beds.
(C) Public facilities will be reimbursed
using either the statewide or facility-specific interim rates and settled to
total allowable costs as determined by analyses of the cost reports (Form CMS
2552) filed with the OHCA.
(c) Out-of-state services.
(1)
Border and "border status"
placements. Facilities are reimbursed in the same manner as in-state
hospitals or PRTFs. Refer to OAC
317:30-3-90
and
317:30-3-91.
(2)
Out-of-state
placements. In the event comparable services cannot be purchased from an
Oklahoma facility and the current payment levels are insufficient to obtain
access for the member, the OHCA may negotiate a predetermined, all-inclusive
per diem rate for specialty programs/units. An incremental payment adjustment
may be made for one (1): one (1) staffing (if clinically appropriate and prior
authorized). Payment may be up to, but no greater, than usual and customary
charges. The one (1): one (1) staffing adjustment is limited to sixty (60) days
annually. Refer to OAC
317:30-3-90
and
317:30-3-91.
(d) Add-on payments.
(1) Additional payment shall
only be made for services that have been prior authorized by OHCA or its
designee and determined to be medically necessary. For medical necessity
criteria applicable for the add-on payment(s), refer to the SoonerCare Medical
Necessity Criteria Manual for Inpatient Behavioral Health Services found on the
OHCA website.
(2) SoonerCare shall
provide additional payment for the following services rendered in an Acute II
and PRTF, as per the Oklahoma Medicaid State Plan.
(A)
Intensive treatment services (ITS)
add-on. Payment shall be made for members requiring intensive staffing
supports.
(B)
Prospective
complexity add-on. Payment shall be made to recognize the increased cost
of serving members with a mental health diagnosis complicated with non-verbal
communication.
(C)
Specialty
add-on. Payment shall be made to recognize the increased cost of serving
members with complex needs.
(e) Services provided under arrangement.
(1)
Case management
transitioning services.
(A) Services
for the provision of case management transitioning services to existing members
are considered to be inpatient psychiatric services, when services exceed and
do not duplicate ordinary inpatient discharge planning during the last thirty
(30) days of a covered acute or residential stay.
(B) Payment for case management transitioning
services provided under arrangement with the inpatient provider will be
directly reimbursed to a qualified community-based provider.
(2)
Evaluation and
psychological testing by a licensed psychologist.
(A) Services for the provision of evaluation
and psychological testing by a licensed psychologist to existing members are
considered to be inpatient psychiatric services, when services exceed and do
not duplicate ordinary inpatient discharge planning during the last thirty (30)
days of a covered acute or residential stay.
(B) Payment for evaluation and psychological
testing by a licensed psychologist for services provided under arrangement with
the inpatient provider will be directly reimbursed to a qualified provider in
accordance with the Oklahoma Medicaid State Plan.
Added at 23 Ok Reg 2508, eff 6-25-06; Amended at 27 Ok Reg 710, eff 2-4-10 (emergency); Amended at 27 Ok Reg 1470, eff 6-11-10; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended at 28 Ok Reg 1452, eff 6-25-11
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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