Okla. Admin. Code § 317:30-5-356
Current through Vol. 41, No. 19, June 17, 2024
Section 317:30-5-356 - Coverage for adults Payment is made to RHCs for adult services as set forth in this Section.
(1)RHC services. Payment is made for one (1) encounter per member per day. Payment is also limited to four (4) visits per member per month. 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. Preventive service exceptions include:(A)Obstetrical care. An RHC should have a written contract with its physician, PA, APRN, or CNM that specifically identifies how obstetrical care will be billed to SoonerCare, in order to avoid duplicative billing situations. The agreement should also specifically identify the physician's compensation for RHC and other ambulatory services.(i) If the clinic compensates the physician, PA, APRN, or CNM to provide obstetrical care, then the clinic must bill the SoonerCare program for each prenatal visit using the appropriate CPT evaluation and management codes.(ii) If the clinic does not compensate its practitioners to provide obstetrical care, then the independent practitioner must bill the OHCA for prenatal care according to the global method described in the SoonerCare provider specific rules for physicians, PAs, APRNs and CNMs (refer to OAC 317:30-5-22) .(iii) Under both billing methods, payment for prenatal care includes all routine or minor medical problems. No additional payment is made to the prenatal provider except in the case of a major illness distinctly unrelated to pregnancy.(B)Family planning services. Family planning services are available only to members with reproductive capability. Family planning visits do not count as one (1) of the four (4) RHC visits per month.(2)Other ambulatory services. These services are not considered a part of an RHC visit; therefore, these may be billed to the SoonerCare program by the RHC or service provider on the appropriate claim form. Refer to OAC 317:30-1, General Provisions, and OAC 317:30-3-57, 317:30-5-59, and 317:30-3-60 for general coverage and exclusions under the SoonerCare program. Some specific limitations are applicable to other ambulatory services as set forth in specific provider rules and excerpted as follows: (A) Coverage under optometrists for adults is limited to treatment of eye disease not related to refractive errors.(B) There is no coverage for eye exams for the purpose of prescribing eyeglasses, contact lenses or other visual aids. (See OAC 317:30-5-431.)Okla. Admin. Code § 317:30-5-356
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 141, eff 10-14-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 21 Ok Reg 501, eff 1-1-04 (emergency); Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 23 Ok Reg 2463, eff 6-25-06; Amended at 26 Ok Reg 113, eff 8-1-08 (emergency); Amended at 26 Ok Reg 1066, eff 5-11-09Amended by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015Amended by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016Amended by Oklahoma Register, Volume 34, Issue 23, August 15, 2017, eff. 9/1/2017Amended by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/1/2021Amended by Oklahoma Register, Volume 39, Issue 10, February 1, 2022, eff. 12/21/2021Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022