OHCA Policies and Rules
317:30-5-240.1. Definitions
[Revised 09-12-22]
The following words or terms, when used in this Part, shall have the following meaning, unless the context clearly indicates otherwise:
"Accrediting body" means one (1) of the following:
(A) Accreditation Association for Ambulatory Health Care (AAAHC);
(B) American Osteopathic Association (AOA);
(C) Commission on Accreditation of Rehabilitation Facilities (CARF);
(D) Council on Accreditation of Services for Families and Children, Inc. (COA);
(E) The Joint Commission (TJC) formerly known as Joint Commission on Accreditation of Healthcare Organizations;
(F) Accreditation Commission for Health Care (ACHC); or
(G) Other OHCA approved accreditation.
"Adult" means an individual twenty-one (21) and over, unless otherwise specified.
"AOD" means alcohol and other drug.
"AODTP" means alcohol and other drug treatment professional.
"ASAM" means the American Society of Addiction Medicine.
"ASAM patient placement criteria (ASAM PPC)" means the most current edition of the American Society of Addiction Medicine's published criteria for admission to treatment, continued services, and discharge.
"Behavioral health (BH) services" means a wide range of diagnostic, therapeutic, and rehabilitative services used in the treatment of mental illness, substance abuse, and co-occurring disorders.
"BHAs" means behavioral health aides.
"Certifying agency" means the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS).
"C.F.R." means Code of Federal Regulations.
"Child" means an individual younger than twenty-one (21), unless otherwise specified.
"Client Assessment Record (CAR)" means the standardized tool recognized by OHCA and ODMHSAS to evaluate the functioning of the member as per the OHCA prior authorization manual on the OHCA'S website at www.oklahoma.gov/ohca.
"CM" means case management.
"Cultural competency" means the ability to recognize, respect, and address the unique needs, worth, thoughts, communications, actions, customs, beliefs and values that reflect an individual's racial, ethnic, age group, religious, sexual orientation, and/or social group.
"DSM" means the most current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
"EBP" means an evidence-based practice per the Substance Abuse & Mental Health Services Administration (SAMHSA).
"EPSDT" means the Early and Periodic Screening, Diagnostic and Treatment benefit for children. In addition to screening services, EPSDT also covers the diagnostic and treatment services necessary to ameliorate acute and chronic physical and mental health conditions.
"FBCS" means facility-based crisis stabilization.
"FSPs" means family support providers.
"ICF/IID" means intermediate care facility for individuals with intellectual disabilities.
"Institution" means an inpatient hospital facility or institution for mental disease (IMD).
"IMD" means institution for mental disease as per 42 C.F.R. ' 435.1009 as a hospital, nursing facility, or other institution of more than sixteen (16) beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. The regulations indicate that an institution is an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases. Title XIX of the Social Security Act provides that, except for individuals under age twenty-one (21) receiving inpatient psychiatric care, Medicaid (Title XIX) does not cover services to IMD patients under sixty-five (65) years of age [Section 1905(a)(24)(B) of the Social Security Act].
"Level of functioning rating" means a standardized mechanism to determine the intensity or level of services needed based upon the severity of the member's condition. The CAR level of function rating scale is the tool that links the clinical assessment to the appropriate level of Mental Health treatment. Either the Addiction Severity Index (ASI) or the Teen Addiction Severity Index (TASI), based on age, is the tool that links the clinical assessment to the appropriate level of Substance Abuse (SA) treatment.
"LBHP" means a licensed behavioral health professional.
"MST" means the EBP Multi-Systemic Therapy.
"OAC" means the publication authorized by 75 Oklahoma Statutes, Sec. 256 known as The Oklahoma Administrative Code, or, prior to its publication, the compilation of codified rules authorized by 75 O.S. ' 256(A)(1)(a) and maintained in the Office of Administrative Rules.
"Objectives" means a specific statement of planned accomplishments or results that are specific, measurable, attainable, realistic, and time limited.
"ODMHSAS" means the Oklahoma Department of Mental Health and Substance Abuse Services.
"ODMHSAS contracted facilities" means those providers that have a contract with the ODMHSAS to provide mental health or substance use disorder treatment services, and contract directly with the Oklahoma Health Care Authority to provide outpatient behavioral health services.
"OHCA" means the Oklahoma Health Care Authority.
"OJA" means the Office of Juvenile Affairs.
"O.S." means Oklahoma Statutes.
"RBMS" means residential behavioral management services within a group home or therapeutic foster home.
"Recovery" means an ongoing process of discovery and/or rediscovery that must be self defined, individualized and may contain some, if not all, of the ten fundamental components of recovery as outlined by SAMHSA.
"PRSS" means peer recovery support specialist.
"SAMHSA" means the Substance Abuse and Mental Health Services Administration.
"Serious emotional disturbance (SED)" means a condition experienced by persons from birth to eighteen (18) that show evidence of points of (A), (B) and (C) below:
(A) The disability must have persisted for six (6) months and be expected to persist for a year or longer.
(B) A condition or serious emotional disturbance as defined by the most recently published version of the DSM or the International Classification of Disease (ICD) equivalent with the exception of DSM "V" codes, substance abuse, and developmental disorders which are excluded, unless they co-occur with another diagnosable serious emotional disturbance.
(C) The child must exhibit either (i) or (ii) below:
(i) Psychotic symptoms of a serious mental illness (e.g., Schizophrenia characterized by defective or lost contact with reality, often hallucinations or delusions); or
(ii) Experience difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. There is functional impairment in at least two (2) of the following capacities (compared with expected developmental level):
(I) Impairment in self-care manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
(II) Impairment in community function manifested by a consistent lack of age-appropriate behavioral controls, decision-making, judgment and value systems which result in potential involvement or involvement with the juvenile justice system.
(III) Impairment of social relationships manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults.
(IV) Impairment in family function manifested by a pattern of disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents, disregard for safety and welfare or self or others (e.g., fire setting, serious and chronic destructiveness, inability to conform to reasonable limitations and expectations which may result in removal from the family or its equivalent).
(V) Impairment in functioning at school manifested by the inability to pursue educational goals in a normal time frame (e.g., consistently failing grades, repeated truancy, expulsion, property damage or violence toward others).
"Serious mental illness (SMI)" means a condition experienced by persons age eighteen (18) and over that show evidence of points of (A), (B) and (C) below:
(A) The disability must have persisted for six (6) months and be expected to persist for a year or longer.
(B) A condition or serious mental illness as defined by the most recently published version of the DSM or the International Classification of Disease (ICD) equivalent with the exception of DSM "V" codes, substance abuse, and developmental disorders which are excluded, unless they co-occur with another diagnosable serious mental illness.
(C) The adult must exhibit either (i) or (ii) below:
(i) Psychotic symptoms of a serious mental illness (e.g., Schizophrenia characterized by defective or lost contact with reality, often hallucinations or delusions); or
(ii) Experience difficulties that substantially interfere with or limit an adult from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. There is functional impairment in at least two (2) of the following capacities (compared with expected developmental level):
(I) Impairment in self-care manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
(II) Impairment in community function manifested by a consistent lack of appropriate behavioral controls, decision-making, judgment and value systems which result in potential involvement or involvement with the criminal justice system.
(III) Impairment of social relationships manifested by the consistent inability to develop and maintain satisfactory relationships with peers.
(IV) Impairment in family function manifested by a pattern of disruptive behavior exemplified by repeated and/or unprovoked violence, disregard for safety and welfare of self or others (e.g., fire setting, serious and chronic destructiveness, inability to conform to reasonable limitations and expectations).
(V) Impairment in functioning at school or work manifested by the inability to pursue educational or career goals.
"Trauma informed" means the recognition and responsiveness to the presence of the effects of past and current traumatic experiences in the lives of members.
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.
