Current through Vol. 42, No. 1, September 16, 2024
(a)
Purpose. Drug testing is performed for undisclosed drug use and/or
abuse, and to verify compliance with treatment. Testing for drugs of abuse to
monitor treatment compliance should be included in the treatment plan for pain
management when chronic opioid therapy is involved.
(1) Qualitative (presumptive) drug testing
may be used to determine the presence or absence of a drug or drug metabolite
in the sample and is expressed as a positive or negative result. Qualitative
testing can be performed by a Clinical Laboratory Improvement Amendment of 1988
(CLIA) waived or moderate complexity test, or by a high complexity testing
method.
(2) Quantitative
(definitive) drug testing is specific to the drug or metabolite being tested
and is expressed as a numeric result or numeric level which verifies
concentration.
(3) Specimen
validity testing is used to determine if a specimen has been diluted,
adulterated, or substituted. Specimen validity tests include, but are not
limited to, creatinine, oxidants, specific gravity, urine pH, nitrates, and
alkaloids.
(b)
Eligible providers. Providers performing drug testing should have
CLIA certification specific to the level of testing performed as described in
Oklahoma Administrative Code (OAC)
317:30-5-100(1)(A).
(c)
Compensable services. Drug
testing must be ordered by the physician or non-physician provider and must be
individualized to the member and the member's medical history and/or assessment
indicators as evidenced in the medical documentation.
(1) Compensable testing must be medically
indicated as evidenced by member specific indications in the medical record.
(A) Testing is only compensable if the
results will affect member care.
(B) Drugs or drug classes being tested should
reflect only those likely to be present.
(2) The frequency of drug screening and/or
testing is determined by the member's history, member's physical assessment,
behavioral assessment, risk assessment, treatment plan and medication
history.
(3) Quantitative
(definitive) drug testing may be indicated for the following:
(A) To identify a specific substance or
metabolite that is inadequately detected or undetectable by a qualitative
(presumptive) test; or
(B) To
definitively identify specific drugs in a large family of drugs; or
(C) To identify drugs when a definitive
concentration of a drug is needed to guide management; or
(D) To identify a negative, or confirm a
positive, qualitative (presumptive) result that is inconsistent with a member's
self-report, presentation, medical history or current prescribed medication
plan; or
(E) To identify a
non-prescribed medication or illicit use for ongoing safe prescribing of
controlled substances.
(d)
Non-compensable services.
The following tests are not medically necessary and therefore not covered by
the OHCA:
(1) Specimen validity testing is
considered a quality control measure and is not separately
compensable;
(2) Drug testing for
member sample sources of saliva, oral fluids, or hair;
(3) Testing of two (2) different specimen
types (urine and blood) from the same member on the same date of
service;
(4) Drug testing for
medico-legal purposes (court-ordered drug screening) or for employment
purposes;
(5) Non-specific, blanket
panel or standing orders for drug testing, routine testing of therapeutic drug
levels, or drug panels which have no impact to the member's plan of
care;
(6) Scheduled and routine
drug testing (i.e., testing should be random);
(7) Reflex testing for any drug is not
medically indicated without specific documented indications;
(8) Confirmatory testing exceeding three
specific drug classes at an interval of greater than every thirty (30) days
will require specific documentation in the medical record to justify the
medical necessity of testing; and
(9) Quantitative (definitive) testing of
multiple drug levels that are not specific to the member's medical history and
presentation are not allowed. Justification for testing for each individual
drug or drug class level must be medically indicated as reflected in the
medical record documentation.
(e)
Documentation requirements.
The medical record must contain documents to support the medical necessity of
drug screening and/or testing. Medical records must be furnished on request and
may include, but are not limited to, the following:
(1) A current treatment plan;
(2) Member history and physical;
(3) Review of previous medical records if
treated by a different physician for pain management;
(4) Review of all radiographs and/or
laboratory studies pertinent to the member's condition;
(5) Opioid agreement and informed consent of
drug testing, as applicable;
(6)
List of prescribed medications;
(7)
Risk assessment, as identified by use of a validated risk assessment
tool/questionnaire, with appropriate risk stratification noted and
utilized;
(8) Office/provider
monitoring protocols, such as random pill counts; and
(9) Review of prescription drug monitoring
data or pharmacy profile as warranted.
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 14 Ok Reg 757, eff 1-24-97 (emergency); Amended at 14 Ok
Reg 1792, eff 5-27-97; Amended at 14 Ok Reg 2394, eff 5-28-97 (emergency);
Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 3413, eff 7-1-99
(emergency); Amended at 17 Ok Reg 1204, eff
5-11-00
