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MAC Meeting Agenda

May 20, 2010 at 1 p.m.
OHCA Board Room
4545 N. Linicoln, Suite 124
Oklahoma City, OK 73105

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Tentative Agenda

I. Welcome, Roll Call, and Public Comment Instructions

II. Approval of minutes of the March 25, 2010 Medical Advisory Committee Meeting

III. MAC Member Comments/Discussion

IV. Legislative Report:  Nico Gomez, Deputy Chief Executive Officer

V. Financial Report: Carrie Evans, Chief Financial Officer

VI. Program Operations & Benefits Update: Becky Pasternik-Ikard, Chief Operating Officer

VII. Provider Services Support Update: Paul Keenan, MD, Chief Medical Officer

VIII. Action Items: Traylor Rains, Policy Development Coordinator

OHCA Initiated

10-04 Federally Qualified Health Center Rules - Rules are revised to clarify reimbursement methods for providers of FQHCs and their relationship to the Prospective Payment System (PPS) rate.  Currently rules are not clear as to which providers would be reimbursed the PPS rate for services provided. Additionally, rules are revised to clarify requirements for FQHC contracting and behavioral health services provided in school settings.

  • Budget Impact – Budget savings estimated

10-17 Dental Rules - Dental rules are revised to limit emergency extractions to three per day, clarify treatment parameters for tooth decay, clarify the supporting documentation required to accompany x-rays submitted to the OHCA and clarify that the required follow-up service for certain failed procedures will be performed, even if the member is no longer SoonerCare eligible. Policy is also revised to set limitations on the types of crowns that can be used for certain teeth, revise the recoupment period for defective restorative services and revise the length of time before a permanent restorative service can be performed again on the same tooth. Orthodontic revisions are needed to clarify eligibility requirements, limits on the types of orthodontic therapy allowed, the documentation required in order to receive prior authorization for orthodontic services and progress reporting.  Other minor policy revisions are also included.

  • Budget Impact - $2,836,258 Total Savings $685,524 State Share Savings 

10-19 Targeted Case Management Rules – Rules are being revised to remove policy that allows reimbursement for behavioral health case manager's travel time to and from meetings for the purpose of development or implementation of the individual plan of care. Current policy conflicts with the Agency's SPA methodology which includes behavioral health case manager's travel time as a component of the case management rate. Additionally, rules are revised to revoke sections that were previously combined with other areas of policy.

  • Budget Impact - Budget Neutral

10-20 Smoking and Tobacco Use Cessation Counselling - Indian Health Rules are revised to clarify that smoking and tobacco use cessation counseling is a covered service through facilities of the Indian Health Service, tribal facilities and Urban Indian Clinics (I/T/U's). 

  • Budget Impact – Budget Neutral

10-23 Private Duty Nursing - Private duty nursing rules are revised to provide additional clarification in regards to prior authorization requests for such services.  Revisions clarify that providers should submit the required OHCA forms and documentation along with the treatment plan when requesting the prior authorization for private duty nursing.  Revisions also provide additional flexibility for OHCA to conduct a preliminary telephonic interview with members prior to arranging a personal visit.  The additional flexibility in allowing the telephonic interview will provide an opportunity for OHCA to ensure medical necessity prior to arranging the personal home visit.  Additional revisions include general policy cleanup as it relates to these sections.

  • Budget Impact – Budget Neutral

10-24 DMEPOS Delivery - Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) rules are revised to provide guidance regarding the delivery of DMEPOS products.  Rules provide clarification and guidelines for product refills and reorders, including expected utilization patterns, member contact, and timelines.  Rules also provide additional guidance in regards to products which are supplied and delivered via mail and the appropriate way for providers to bill for such items.  Additional revisions include clarification in regards to the provider cost of delivery and additional language to clarify OHCA's intent on DMEPOS supplier maintenance in regards to equipment-related services.

  • Budget Impact – Budget Neutral

10-25 SoonerCare Referrals - SoonerCare Choice rules are revised to include procedures and guidelines related to primary care provider (PCP) referrals under the current medical home model.  The PCP referral process is clearly defined, including the appropriate use of OHCA administrative referrals.  Rules further explain provider expectations and provide guidelines regarding PCP referrals, medical necessity, medical record documentation, and OHCA administrative referrals.  These revisions continue to strengthen the OHCA medical home model and SoonerCare Choice program.

  • Budget Impact – Budget Neutral

10-27 Team Therapy - Agency rules are revised to provide guidance in regards to team therapy.  Physical, occupational, and speech therapy rules will clarify that when multiple therapists, or therapy assistants, work together as a team to treat one or more SoonerCare members, each therapist or assistant cannot bill separately for the same or different service provided at the same time to the same member.  Additionally, rules will provide clarification in regards to billing, multiple therapies, delivery of service, and determining the time counted for service units and codes.

  • Budget Impact – Budget Neutral

10-28 Online Enrollment/TPL Rules - In 2007, the OHCA received a Transformation Grant through the Centers for Medicare and Medicaid Services (CMS) to develop a web based online application and eligibility determination system in order to improve the ease and efficiency of enrollment.  The Online Enrollment process allows potential members to apply for SoonerCare electronically.  Soon, the OHCA will assume responsibility for determining eligibility for certain groups of individuals under SoonerCare through this process.  As OHCA will now be making eligibility determinations, our rules regarding Third Party Liability are in need of revision to update. 

  • Budget Impact – Budget Neutral

10-29 Outpatient Behavioral Health Rules – Rules are revised to clarify the definition and credential requirements of a Behavioral Health Rehabilitation Specialists (BHRS).Current policy conflicts with Oklahoma Department of Mental Health Substance Abuse Services (ODMHSAS) definition and credential requirements. Additionally, rules are revised to clean up discrepancies between OHCA and ODMHSAS policy for consistency.

  • Budget Impact – Budget Neutral

10-30 Inpatient Psychiatric Hospital Rules – Rules are being revised to modify Residential Treatment Center (RTC) requirements for Community Based transitional level of care.  Modifications allow the requirements to be less restrictive as a step-down from standard RTC. By reducing the treatment requirements for the Community Based Transitional level of care, this allows facilities to step down that member to a lower level of RTC care and focus on transitioning the member back to the community, which supports RTC diversion.  Additionally, rules are revised to add the Child and Adolescent Level of Care Utilization System (CALOCUS) to be used when determining level of care. Other revisions include removing medical necessity from policy and directing providers to reference the OHCA Behavioral Health Provider Manual.

  • Budget Impact – Total annual savings of $500,000.00 expected

10-31 Grievance Procedure Rules - OHCA grievance procedure rules are revised to provide for an appeals process for purchasing decisions made internally at OHCA, pursuant to 74 Okla. Stat., § 85.5 (T). Further revisions are made to clean up terminology within the existing language. These revisions are needed to provide immediate consistency and clarity within agency purchasing rules.

  • Budget Impact – Budget Neutral

IX. New Business

X. Adjourn

Next Meeting:  Thursday, July 22, 2010


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