Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 8 - REHABILITATION HOSPITALS
Section 317:30-5-111 - Coverage for adults
Current through Vol. 41, No. 20, July 1, 2024
For persons twenty-one (21) years of age or older, payment is made to hospitals for inpatient services as described in this section.
(1) All general inpatient hospital services which are not provided under the Diagnosis Related Group (DRG) payment methodology for all persons twenty-one (21) years of age or older is limited to ninety (90) days per person per state fiscal year (July 1 through June 30). The ninety (90) day limitation applies to both hospital and physician services. No exceptions or extensions will be made to the ninety (90) day inpatient services limitation.
(2) All inpatient stays are subject to post-payment utilization review by the Oklahoma Health Care Authority's (OHCA) designated Quality Improvement Organization (QIO). These reviews are based on severity of illness and intensity of treatment.
(3) If a hospital or physician believes that a hospital admission or continued stay is not medically necessary and thus not compensable but the member insists on treatment, the member should be informed that he/she will be personally responsible for all charges. If a claim is filed and paid and the service is later denied, the patient is not responsible.
(4) Payment is made to a participating hospital for hospital based physician's services. The hospital must have a Hospital-Based Physician's contract with OHCA for this method of billing.
(5) Outpatient services for adults are covered as listed in Oklahoma Administrative Code 317:30-5-42.1.
Added at 23 Ok Reg 239, eff 10-3-05 (emergency); Added at 23 Ok Reg 1346, eff 5-25-06; Amended at 25 Ok Reg 112, eff 10-1-07 (emergency); Amended at 25 Ok Reg 1192, eff 5-25-08