OHCA Policies and Rules

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317:30-3-5.1. Usual and Customary fees

[Revised 10-01-08]

(a) Providers are required to indicate their usual and customary charge when submitting claims to SoonerCare. The usual and customary charge is the provider's charge for providing the same service to persons not entitled to SoonerCare benefits. For providers using a sliding fee scale, the usual and customary charge is the one that best represents the most frequently charged amount by the individual provider for the service when provided to non-SoonerCare members. Providers that do not have an established usual and customary charge indicate an amount reasonably related to the provider's cost for providing the service.

(b) Providers may not charge SoonerCare a higher fee than they charge non-SoonerCare patients even if the SoonerCare allowable is greater than the provider's usual and customary fee. Unless otherwise permitted by SoonerCare reimbursement methodology, individual claim payments are limited to the lesser of their usual and customary charge or the SoonerCare allowable.

(c) Providers indicate their usual and customary charge without deducting the co-payment for services that require a member co-payment. When applicable, the co-payment is systematically deducted.

(d) Payment is made based on the amount of the claim submitted, up to the maximum allowable amount.

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.