Okla. Admin. Code § 317:30-5-95.50

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-95.50 - Residential substance use disorder (SUD) - Reimbursement

(a) In order to be eligible for payment, residential treatment providers of SUD treatment services must have an approved provider agreement on file with the OHCA. Through this agreement, the residential provider assures that they are in compliance with all applicable federal and State Medicaid law and regulations, including, but not limited to, OHCA administrative rules, ODMHSAS administrative rules, and the Oklahoma Medicaid State Plan.

(b) Covered SUD treatment services for adolescents and adults in SUD residential treatment shall be reimbursed utilizing the per diem rates for each level of care. All SUD residential treatment services must be prior authorized by the OHCA or its designated agent before the service is rendered by an eligible provider. Without prior authorization, payment is not authorized.

(c) Separate payment may be made for medications, physician services, and treatment services provided to dependent children in accordance with the Oklahoma Medicaid State Plan. Separate payment for such services will follow existing prior authorization requirements, if applicable.

(d) Treatment services for dependent children accompanying a parent to treatment shall be reimbursed on a fee-for-service basis in accordance with the Oklahoma Medicaid State Plan. Outpatient services rendered to dependent children may be provided by the residential facility if appropriately certified or a separate outpatient provider. Such services shall not duplicate any services provided by the residential provider that are reimbursed through the residential per dime rate.

(e) The following services are excluded from coverage/reimbursement:

(1) Room and board;

(2) Services or components that are not provided to or exclusively for the treatment of the member;

(3) Services or components of services of which the basic nature is to supplant housekeeping or basic services for the convenience of a member receiving covered services;

(4) Physician directed services and medications (these services are reimbursed outside of the residential SUD per diem);

(5) Telephone calls or other electronic contacts (not inclusive of telehealth); and

(6) Field trips, social, or physical exercise activity groups.

Okla. Admin. Code § 317:30-5-95.50

Adopted by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/1/2021

Amended by Oklahoma Register, Volume 40, Issue 24, September 1, 2023, eff. 9/11/2023