OHCA Policies and Rules
317:30-3-59 General program exclusions - adults
[Revised 09-12-22]
The following are excluded from SoonerCare coverage for adults:
(1) Inpatient admission for diagnostic studies that could be performed on an outpatient basis.
(2) Services or any expense incurred for cosmetic surgery.
(3) Services of two (2) physicians for the same type of service to the same member on the same day, except when supplemental skills are required and different specialties are involved.
(4) Refractions and visual aids.
(5) Pre-operative care within twenty-four (24) hours of the day of admission for surgery and routine post-operative care as defined under the global surgery guidelines promulgated by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS).
(6) Sterilization of members who are under twenty-one (21) years of age, mentally incompetent, or institutionalized or reversal of sterilization procedures for the purposes of conception.
(7) Non-therapeutic hysterectomies.
(8) Induced abortions, except when certified in writing by a physician that the abortion was necessary due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed, or that the pregnancy is the result of an act of rape or incest.
(9) Medical services considered experimental or investigational. For more information regarding coverage of clinical trials, see Oklahoma Administrative Code (OAC) 317:30-3-57.1.
(10) Services of a certified surgical assistant.
(11) Services of a chiropractor. Payment is made for chiropractor services on crossover claims for coinsurance and/or deductible only.
(12) Services of an independent licensed physical therapist and/or licensed physical therapist assistant. Per OAC 317:30-5-291.
(13) Services of an independent licensed occupational therapist and/or occupational therapist assistant. Per OAC 317:30-5-296.
(14) Services of a psychologist.
(15) Services of an independent licensed speech-language pathologist, speech-language pathology assistant (SLPA), and/or speech-language clinical fellow. Per OAC 317:30-5-675.
(16) Payment for more than four (4) outpatient visits per month (home or office) per member, except those visits in connection with family planning or related to emergency medical conditions.
(17) Payment for more than two (2) long-term care facility visits per month.
(18) More than one (1) inpatient visit per day per physician.
(19) Payment for removal of benign skin lesions.
(20) Physician services which are administrative in nature and not a direct service to the member including such items as quality assurance, utilization review, treatment staffing, tumor board review or multidisciplinary opinion, dictation, and similar functions.
(21) Charges for completion of insurance forms, abstracts, narrative reports or telephone calls.
(22) Payment for the services of social workers, licensed family counselors, registered nurses or other ancillary staff, except as specifically set out in the Oklahoma Health Care Authority (OHCA) rules.
(23) Mileage.
(24) A routine hospital visit on the date of discharge unless the member expired.
(25) Direct payment to perfusionist as this is considered part of the hospital reimbursement.
(26) Fertility treatment.
(27) Payment to the same physician for both an outpatient visit and admission to hospital on the same date.
Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.
