OHCA Policies and Rules

OHCA Policies and Rules Main Page

317:30-5-103. Coverage and payment

[Revised 09-11-23]

(a) Payment eligibility. To be eligible for payment as a laboratory/pathology service, the service must be:

(1) Ordered and provided by or under the direction of a physician or other licensed practitioner within the scope of practice as defined by state law;

(2) Provided in a hospital, physician, or independent laboratory;

(3) Directly related to the diagnosis and treatment of a medical condition;

(4) Authorized under the laboratory's Clinical Laboratory Improvement Amendment of 1988 (CLIA) certification; and

(5) Considered medically necessary as defined in Oklahoma Administrative Code 317:30-3-1(f) and 317:30-5-100.

(b) Payment for inpatient/outpatient services. Payment is made to laboratories for medically necessary services to children and adults as follows:

(1) Inpatient services.

(A) Claims for inpatient anatomical pathology must be billed by the individual pathologist performing the examination.

(B) Inpatient consultations by pathologists are compensable. Claim form must include referring physician, diagnosis, and test(s) for which the consultation was requested.

(2) Outpatient services.

(A) For children, payment is made for medically necessary outpatient clinical laboratory services which are provided in conjunction with physician office visits that are compensable under EPSDT.

(B) For adults, payment is made for medically necessary outpatient services.

(c) Payment rates. Payment will be made for covered laboratory services in accordance with methodology approved under the Oklahoma Medicaid State Plan.

(d) Vocational rehabilitation. Payment for laboratory services is made for those vocational rehabilitation services which are preauthorized by the member's counselor.

(e) Individuals eligible for Part B of Medicare. Payment is made utilizing the Medicaid allowable for comparable services.

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.