Current through Vol. 42, No. 1, September 16, 2024
(a)
Bariatric
surgery. Gastric bypass and other types of weight-loss surgery, known as
bariatric surgery, makes surgical changes to the stomach and digestive system,
limits food intake and nutrient absorption, which leads to weight
loss.
(b)
Eligible
providers. Bariatric surgery providers must be:
(1) Certified by the American College of
Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP) as a Comprehensive Bariatric Surgery Center; or
(2) Currently participating in a
comprehensive multidisciplinary bariatric surgery quality assurance program and
a clinical outcomes assessment review as a pathway to accreditation; and
(3) Completed a fellowship
training in bariatric surgery or be a fellow of the American Society of
Metabolic and Bariatric Surgery (ASMBS) or a MBSAQIP verified surgeon; and
(4) Contracted with the Oklahoma
Health Care Authority (OHCA); and
(5) Have a demonstrated record of quality
assurance.
(c)
Documentation. All documentation submitted to request services
must demonstrate, through adequate objective medical records, evidence
sufficient to justify the member's need for the service, in accordance with OAC
317:30-3-1(f).
Documentation requirements include, but are not limited to:
(1) Documents sufficient to show that member
is between the ages of fifteen (15) to sixty-five (65);
(2) Psychosocial evaluation;
(3) Independent medical evaluation by a
health care professional with dedicated expertise in the care of bariatric
surgery patients;
(4) Surgical
evaluation by an OHCA-contracted surgeon who is credentialed to perform
bariatric surgery;
(5) Record on
participation in a nutrition and lifestyle modification program under the
supervision of an OHCA contracted medical provider; and
(6) For full guidelines, please refer to
www.okhca.org/mau.
(d)
Non-covered services.
(1) Procedures considered experimental or
investigational are not covered.
(2) The OHCA may withdraw authorization of
payment for the bariatric surgery at any time if the OHCA determines that the
member, provider, or bariatric program is not in compliance with any of the
requirements.
(e)
Reimbursement.
(1) Reimbursement
shall only be made for services that have been prior-authorized by OHCA or its
designee.
(2) To be eligible for
reimbursement, bariatric surgery providers must meet the requirements listed in
(b) (1) through (5) of this Section.
(3) Payment shall be made at the lower of the
provider's usual and customary charge or the OHCA fee schedule for Medicaid
compensable services and in accordance with the Oklahoma Medicaid State
Plan.
Added at 24 Ok Reg
141, eff 10-8-06 (emergency); Added at 24 Ok Reg 890, eff 5-11-07; Amended at
27 Ok Reg 450, eff 12-3-09 (emergency); Amended at 27 Ok Reg 939, eff
5-13-10
