Population Care Management (PCM) Programs and Services

• The member’s OB provider initiates High-Risk OB program through the medical prior authorization process. 
• Once approved, the member receives an enhanced HROB benefit package, and a nurse care manager follows up throughout the pregnancy.
• The member receives assistance in accessing various resources and services for the newborn.

• HROB PA Overview  
• HROB Qualified Diagnosis
• HROB Contracted MFM (Maternal Fetal Medicine) Directory
  

• Members are identified for OB Care Management if they are prescribed certain medications for a history of pre-term labor.
• Members and Providers can request OB Care Management directly by contacting the Population Care Management Department, 877-252-6002.

• Private Duty Nursing (PDN) is medically necessary care provided on a regular basis by a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
• This benefit is available to SoonerCare children up to age 21 who have complex special health care needs may qualify for in-home nursing service as part of the SoonerCare PDN benefit package.
• These children require community-based alternatives to institutional care.
• Members are determined to be eligible for PDN through the medical authorization process.
• A Population Nurse Care Manager completes face-to-face assessments (telephonic and face-to-face) that is utilized by a physician in the Medical Professional Services Unit to determine the member’s qualification for PDN services.
• These assessments are completed when the provider submits an initial request for services and then the Nurse Care Managers provides periodic reassessments (telephonic and face-to-face) for Private Duty Nursing services, as well as Care Management support.

Oklahoma Cares - Breast and Cervical Cancer Treatment Program

• This program provides SoonerCare benefits to qualifying women in need of treatment (including diagnostic services) for breast and/or cervical cancer. This program is a partnership between OHCA, Oklahoma State Department of Health, Cherokee National and Kaw Nation. Specific medical and financial criteria must be met to qualify.
• Application for the program is initiated by a certified screener. To find a screener:
  • Oklahoma State Department of Health: 866-550-5585
  • Cherokee Nation - 800-256-0671 Ext. 5442 or 918-453-5442
  • Kaw Nation - 580-362-1039 Ext. 229
• Care Managers in Population Care Management participate in the clinical review of applications and provide care management services to women through their enrollment in the program.

• Nurse Care Managers provide care coordination to members in need of services that are a significant distance from their home, generally 50 miles or more, and/or out of state.
• These services often involve coordination of the authorization to receive care, transportation assistance, and meals/lodging assistance.
  

• Care management is available for members with complex care coordination needs. Care managers work with primary care providers and members to coordinate services and follow-up support.