Global Messages

Long Term Care Enhanced Payment Update

TITLE: ICF/IID Vocational & Day Services Enhanced Payment -Update

Run Date: 11/27/2023 – 12/8/2023

PV Type: 03/ 31,34

SFY2024 2nd Quarter Enhanced Payment for Vocational & Day Services will be made on

November 29, 2023

We thank you for your continued service to SoonerCare members.

TITLE: Nursing Facility Pay for Performance (PFP) Payment Update

Run Date: 11/27/2023 – 12/8/2023

PV Type:  03/ 30,35

The SFY 2024 second quarter PFP payment will be made on Nov. 29, 2023

We thank you for your continued service to SoonerCare members.

Providers: 08, 09, 10, 20, 25, 31, 52

Effective Dec. 4, 2023, OHCA will implement prior authorization (PA) requests for 1) cochlear implants, 2) BAHA implants, 3) prosthetics, and 4) orthotics to run through InterQual guidelines that are embedded into the SoonerCare provider portal PA function. Providers will now need to answer questions in InterQual and submit supporting documents for each PA request. Additional information regarding the use of InterQual can be found in the Medical Authorization Using InterQual presentation. 

Providers: 08, 09, 10, 18, 19, 31, 52

Effective Nov. 1, 2023, OHCA has added coverage and limits for ocular prosthetics for expansion adults and children as follows:

V2623 – Prosthetic eye, plastic, custom

• Covered for expansion adults and children with a limit of 1 prosthesis every 5 years; prior authorization (PA) limit override allowed when necessary.

V2624 – Polishing/resurfacing of ocular prosthesis

• Covered for expansion adults and children with a limit of 2 services per year (rolling 12 months); PA limit override allowed when necessary.

V2625 – Enlargement of ocular prosthesis

• Covered for expansion adults and children with a limit of 1 enlargement per prosthesis; limit set for 1 per 5 years with a PA override allowed when necessary.

V2626 – Reduction of ocular prosthesis

• Covered for expansion adults and children with a limit of 1 enlargement per prosthesis; limit set for 1 per 5 years with a PA override allowed when necessary.

V2627 – Scleral cover shell

• Covered for expansion adults and children.

V2628 – Fabrication and fitting of ocular conformer

• Covered for expansion adults and children.

V2629 – Prosthetic eye, other type

• Covered for expansion adults and children – PA required, manual pricing.

Provider Types/Specialties: All

Oklahoma Health Care Authority has partnered with Unite Oklahoma to help SoonerCare members who may no longer be eligible for coverage with finding alternative forms of coverage and other supportive services. Unite Oklahoma is a network that brings together community-based organizations, health care providers and government agencies.

To request help, please fill out the Unite Us form.

Provider Types/Specialties: All

To ensure that all provider files are up to date, the Oklahoma Health Care Authority would like to remind providers to log into the secure provider portal to make sure that your provider address, contact information and other demographic information is correct.  This information can be checked and corrected by selecting the Update Provider Files link once logged in to the admin account.

Providers: 08, 09, 10, 31, and 52

Effective Nov. 1, 2023, OHCA has added coverage for extended ambulatory cardiac monitoring codes 93241-93244 and 93245-93248. Coverage is intended to evaluate syncope and lightheadedness, to document arrhythmia in members with a non-diagnostic Holter monitor or 48-hour telemetry, or in persons whose symptoms occur infrequently such that the arrhythmia is unlikely to be diagnosed by Holter monitoring. 

Providers: All

Effective Nov. 1, 2023, OHCA will now reimburse for COVID vaccine counseling to and for the benefit of SoonerCare members ages 0-20 when the vaccine is not administered the same day, using HCPCS G0315 - Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21, 5-15 minutes, instead of 99401 which was previously used to report this service. The claim line for G0315 must include either diagnosis code Z28.310 or Z28.310.

• Code Z28.310, unvaccinated for COVID, may be assigned when the patient has not received at least one dose of any COVID vaccine.
• Code Z28.311, partially vaccinated for COVID, may be assigned when the patient has received at least one dose of a multi-dose COVID vaccine regimen, but has not received the full set of doses necessary to meet the Centers for Disease Control and Prevention (CDC) definition of ‘fully vaccinated’ at the time of the encounter.

A counseling visit is a conversation between a provider and a patient, parent or guardian about the COVID vaccine. Conversations may include topics such as patient’s reasons for not being vaccinated, addressing concerns identified by the patient, providing tailored and individualized medical advice regarding COVID vaccine for that patient, and providing resources about how to get a COVID vaccine if applicable. Counseling visits should be documented in a patient’s medical record according to standard documentation guidelines. It would not be appropriate to bill for this additional service just for checking vaccination status.

Providers: All

OHCA has updated coverage of Respiratory Syncytial Virus (RSV) vaccines and monoclonal antibodies for the 2023-2024 RSV season as follows:

Adults:

• ABRYSVO™ - 90678 Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use.
  • Covered for ages 60+
  • Covered for pregnant members during 32-36 weeks’ gestation.  *See note below regarding use of both ABRYSVO and Beyfortus™ to prevent RSV in infants.
• AREXVY - 90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use
  • Covered for ages 60+

Children:

• Beyfortus™/Nirsevimab
  • 90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use 
  • 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use
  • 96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional (used only with 90380 or 90381)
  • 96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection (used only with 90380 or 90381)
    
    The recommended dosage of Beyfortus/nirsevimab for neonates and infants born during or entering their first RSV season is based on body weight and is administered as a single intramuscular (IM) injection.
    
    
  • Neonates and infants entering their first RSV season who weigh less than 5 kg should be administered a 50 mg dose.
  • Neonates and infants who weigh 5 kg or more should be administered a 100 mg dose.
    
    For children up to 24 months of age who remain at increased risk for severe RSV in their second RSV season, the recommended dosage of Beyfortus/nirsevimab is a single 200 mg administered as 2 IM injections.

Note: Per ACIP, “Either ABRYSVO RSV maternal vaccination during pregnancy at 32-36 weeks’ gestation or Beyfortus/nirsevimab administration for infants under 8 months shortly before or during the RSV season is recommended to prevent RSV lower respiratory tract infection, but both products are not indicated for most infants.”

• Palivizumab/SYNAGIS®
  • 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, 50 mg

There is no change in current coverage for SYNAGIS. 

Per guidance from the American Academy of Pediatrics, high-risk infants who are recommended to receive SYNAGIS  in the first or second year of life should continue to be treated with SYNAGIS as in prior seasons if Beyfortus is not available. Infants who receive SYNAGIS  at the beginning of the RSV season may be allowed to receive Beyfortus once available in lieu of additional doses of SYNAGIS.

Additional information for RSV vaccines and monoclonal antibodies can be found at the following link:

ACIP Vaccines for Children Program; Vaccines to Prevent Respiratory Symcytial Virus (RSV) (cdc.gov)

Provider Types/Specialties: All

The Oklahoma Health Care Authority is presenting a webinar for SoonerCare providers on Tuesday, Oct. 31. The U.S. is experiencing a maternal mortality crisis, with black pregnant women experiencing rates of maternal deaths three times higher than that of white women. Join us to learn how the Oklahoma Perinatal Quality Improvement Collaborative (OPQIC) is addressing maternal mortality, morbidity and health equity in Oklahoma through a low-dose aspirin in pregnancy initiative.

Visit the OHCA provider training page to register to attend the webinar from 10-11:30 a.m., Tuesday, Oct. 31. After registering, you will receive a confirmation email containing information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Greetings, 

Please join OHCA and our SoonerSelect partners on Wednesday, Oct. 18 in Duncan to learn more about SoonerSelect. The meeting is in person, and you will need to register if you plan to attend. 

When:  Wednesday, Oct. 18 • 10 a.m.

Where:  Red River Technology Center
               3300 W. Bois D'Arc Ave.
               Duncan, Oklahoma

The town hall will provide an opportunity to hear an update from OHCA, ask questions and meet the health, dental and Children’s Specialty Program plans. Learn More About SoonerSelect.

Provider Types/Specialties: All

For information regarding flu vaccine coverage for SoonerCare members, including covered NDCs, visit the pharmacy updates page to view the 2023-2024 flu guidelines. 

Long-Term Care Cost Reports SFY 23  

Run Date: 09/25/2023 – 10/31/2023

PV Type:  03/30, 31, 32, 33, 34, 35

Long-term care provider cost reports for SFY 23 are due by 10/31/23

Facilities may be subject to a rate reduction equal to the amount of the direct care portion of the daily rate, ranging from $24.61 to $56.15 per patient day, if cost reports are not received in a timely manner. 

We thank you for your attention to this matter.

Provider Types/Specialties: All

The Oklahoma Health Care Authority is presenting a webinar for SoonerCare providers on Tuesday, Oct. 3. This presentation will help providers educate and guide members through the SoonerRide program. Included will be a summary overview of the non-emergency medical transportation program as well as new feature highlights of the Modivcare App that will enable members to book and track their rides. The app offers an easy way to submit ride information for mileage reimbursement as well.

Visit the OHCA Provider Training page to register to attend the SoonerRide webinar from 10-11:30 a.m., Tuesday, Oct. 3. After registering, you will receive a confirmation email containing information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Provider types: 08, 09, 10,13, 16, 31, 52

The Focus Forward Oklahoma program works to address issues related to access and utilization of long-acting reversible contraceptives (LARC). There are currently four trainings scheduled: October 2023, December 2023, March 2024 and April 2024.

Focus Forward Oklahoma offers no-cost LARC training to Oklahoma providers, clinical support staff and administrative staff. For more information about Focus Forward and available training, visit our Provider Training web page.

Provider Types/Specialties: 08/080-088; 09/090-093; 10/100, 564; 31/316-318, 320, 345, 564; 52

There currently exists a wide variation in practice among clinicians when identifying and treating high-risk ambulatory patients with COVID-19.

The CRX ECHO will address the implications of variation in practice through an overview of the latest evidence, a case presentation, and an interdisciplinary application-focused discussion facilitated by an Oklahoma clinician.

For more information, visit our Provider Training page.  

Provider Types: 05/050

The Oklahoma Health Care Authority (OHCA) added policies and procedures for Private Duty Nursing (PDN) payment rates. Starting Oct. 1, 2023, the agency will begin accepting electronic claims submission for PDN services for members who qualify for overtime services, by billing a TU modifier. Oklahoma Administrative Code (OAC) 317:30-5-561 states,

(a)  All PDN services, including overtime, are reimbursed per the methodology described in the Oklahoma Medicaid state plan.

(b) Overtime payment for PDN services is only available for nursing staff who are providing services to members with tracheostomies or who are medically dependent on a ventilator for life support at least six (6) hours per day. This excludes members who are on non-invasive CPAP or BiPAP devices only.

(c) In accordance with the Department of Fair Labor Standards Act, a worker must receive overtime pay for every hour that is worked over forty (40) hours in a work week. A work week is defined as any set seven (7) day period. 

OHCA’s goal with this implementation is to increase the automated consistency of overtime claims processing. If you have any questions, please call the OHCA Provider Helpline at 800-522-0114. 

Please join OHCA and our SoonerSelect partners on Friday, Sept. 22 in Tulsa to learn more about SoonerSelect. You'll have an opportunity to hear an update from OHCA, ask questions and meet the health, dental and Children’s Specialty Program plans.

Please register if you plan to attend. This meeting is in-person.

When:  Friday, Sept. 22 • 10 a.m.

Where: Tulsa Technology Centers - Riverside Campus
            Auditorium
            801 E. 81st St.
            Tulsa, Oklahoma

The meeting will be recorded, and a replay will be available at a later date for those who are not able to participate. There will be the opportunity for virtual meetings and additional in-person meetings in the coming months. 

Provider Types/Specialties: All

The Oklahoma Health Care Authority is presenting a webinar for SoonerCare providers on Tuesday, Sept. 26.  During this webinar, providers will be introduced to a web-based policy tool that can assist clinics with customizing a new or updated tobacco-free policy. Topics will include the rationale and benefits relating to adopting a tobacco-free environment policy, updated language, essential and strongly recommended elements, and ways to promote the policy through varies outlets.

Visit the OHCA Provider Training page to register to attend the Tobacco-Free Environmental Policy Overview webinar from 2-3:30 p.m., Tuesday, Sept. 26.

After registering, you will receive a confirmation email containing information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Nursing Facility Pay for Performance (PFP) Payment Update

Run Date: 8/30/2023 – 9/8/2023

PV Type:  03/30, 35

SFY 2024 1st Quarter PFP payment will be made on Aug. 30, 2023.

We thank you for your continued service to SoonerCare members.

Provider Types/Specialties: All

Oklahoma Health Care Authority will present an Oklahoma State Immunization Information System (OSIIS) Data Quality webinar at 2 p.m., Sept. 5. During this webinar, Martin Lansdale, MPH, data quality manager for OSIIS at the Oklahoma State Department of Health, will be shedding light on the crucial topic of OSIIS data quality. Lansdale will explore the importance of data quality and provide valuable insights into the blueprint used to ensure accurate and reliable data. He will also delve into the repercussions of poor data quality within the OSIIS data system, shedding light on the challenges it poses and the potential impact on immunization efforts.

Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Provider Types/Specialties: 11, 63

The Oklahoma Department of Mental Health and Substance Abuse Services is combining two of their most popular conferences, Justice & Recovery and Prevention & Recovery, into one can’t-miss event! Join them at Momentum: Prevention, Justice, Recovery on Dec. 5-7, 2023.

This three-day conference is dedicated to mental health, prevention, recovery, and criminal justice behavioral health. Engage with leaders, gain practical tools, and learn leading strategies in over 40 sessions.

For more information, visit the conference overview web page.

Please join OHCA and our SoonerSelect partners on Monday, Aug. 21 in Enid to learn more about SoonerSelect. You'll have an opportunity to hear an update from OHCA, ask questions and meet the health, dental and Children’s Specialty Program plans.

Please register if you plan to attend. This meeting is in-person.

When:
Monday, Aug. 21 at 11 a.m.

Where:
Autry Technology Center
Room 201
1201 W. Willow Road
Enid, Oklahoma

The meeting will be recorded, and a replay will be available at a later date for those who are not able to participate. There will be the opportunity for virtual meetings and additional in-person meetings in the coming months. Learn More About SoonerSelect.

Provider Types/Specialties: 01, 63

Senate Bill 32x, passed in the 2023 legislative session, directed the Oklahoma Health Care Authority (OHCA) to create and submit a methodology for the disbursement of $200 million in appropriated funds to the Senate Appropriations Committee Chair and the House of Representatives Appropriations and Budget Committee Chair no later than July 31, 2023. The disbursement shall be used for one-time funding to critical access hospitals and hospitals participating in the Supplemental Hospital Offset Payment Program.

On July 17, 2023, the OHCA Board voted to approve a plan for the disbursement of the $200 million for the benefit of Oklahoma hospitals. The methodology, developed in conjunction with a statewide hospital association as directed by SB32x, increases the available funds to hospitals from $200 million to over $285 million and will prioritize hospitals most at-risk.

To maximize the impact of these payments, OHCA will:

• Create a pool of $25 million to be dispersed to identified vulnerable hospitals, defined as having a negative operating margin, less than 45 days of cash on hand and not part of a health care system that does not also meet these criteria.
• Allocate $150 million proportionally based on total Medicaid payments, similar to the existing Supplemental Hospital Offset Payment Program (SHOPP) methodology.
• Use the remaining $25 million to draw down federal matching funds and accelerate the implementation of a new Medicaid hospital payment program based on average commercial reimbursement levels, pending approval from the Centers for Medicare and Medicaid Services (CMS).

To determine eligibility for the vulnerable hospital pool, OHCA will require submission of an attestation. The attestation form will be distributed to hospital contacts today and will also soon be available at SHOPP Forms and Reports. The form will be due by 11:59 CST, Aug. 11, 2023. Please return the completed form to ProvReimb@okhca.org.

Providers: 08/087, 17/170-175

OHCA is expanding the use of telehealth to include certain occupational and physical therapy services. Effective May 12, 2023, OHCA began reimbursing for therapy services utilizing the following service codes delivered via telehealth: 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97535, and 97755.

OHCA asks that providers use modifier GT to denote services were performed utilizing telehealth. For providers unable to submit a claim with the GT modifier for an OHCA approved telehealth-rendered service, please utilize Place of Service (POS) code 02 to denote when telehealth is used. 

An updated list of allowed telehealth services can be found on OHCA’s telehealth page. 

Please join OHCA and our SoonerSelect partners Tuesday, July 18 in Tulsa or Thursday, July 20 in Oklahoma City to learn more about SoonerSelect. You'll have an opportunity to hear an update from OHCA, ask questions and meet the health, dental and Children’s Specialty Program plans.

Please register if you plan to attend. These meetings are in-person.

When: 
1 p.m., Tuesday, July 18

Where: 
Tulsa Technology Center - Owasso Campus
Sycamore Room
10800 N. 137th East Ave.
Owasso, Oklahoma

When:
11 a.m., Thursday, July 20

Where:
Metro Technology Centers - Springlake Campus
Auditorium
1900 Springlake Drive
Oklahoma City, Oklahoma

The meetings will be recorded, and a replay will be available at a later date for those who are not able to participate. There will be the opportunity for virtual meetings and additional in-person meetings in the coming months. 

Learn more about SoonerSelect.

Provider Types/Specialties: 01/011 - 013, 204-206; 03/030, 031, 033-037; 05/050-051, 564; 63/630, 634.

The Oklahoma Health Care Authority is presenting a webinar for SoonerCare providers on Thursday, July 20, that will provide instruction on reviewing and understanding the PASRR requirements and process.

Visit the OHCA Provider Training page to register to attend the PASRR Overview webinar from 10-11:30 a.m., Thursday, July 20.

After registering, you will receive a confirmation email containing information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Provider Types: All

The Office of the State Coordinator for Health Information Exchange is hosting two virtual provider town halls to discuss the new proposed rules surrounding the HIE and the implementation of Oklahoma Senate Bill 1369. The Oklahoma Health Care Authority Agency promulgated permanent rules which were adopted by the OHCA Board on March 22, 2023; however, the proposed rules were disapproved by the Governor on June 23, 2023.

In this meeting, OHCA will review the new rules, explain how to join or register for an exemption, demonstrate the system and discuss its benefits, and answer frequently asked questions. Stakeholders will be encouraged to provide feedback and ask questions regarding the proposed rule changes.

Register in advance:

Tuesday, July 11, 2023 • 3-4:30 p.m. https://www.zoomgov.com/webinar/register/WN_EYmkhUTPQHy2RUN54a1feg

Wednesday, July 19, 2023 • 12-1:30 p.m. https://www.zoomgov.com/webinar/register/WN_CpBLtzzxRj-_egu_Q4OS0Q

After registering, you will receive a confirmation email containing information about joining the meeting. 

TITLE: SFY2023 Cost Report

Run Date: 07/01/2023–10/31/2023

PV Type: 03/30, 31, 34, 35

This is a reminder to LTC providers that all cost reports for the State Fiscal Year ending June 30, 2023, will be due on or before Oct. 31, 2023.

You must report costs electronically via the OHCA Provider Portal unless you are submitting a partial year cost report. All partial year cost reports must be submitted using the Data Entry File for Partial Year Reporting worksheet that can be found on the Long-Term Care Facilities page.

If a change of ownership has occurred and you have an entire year of data available, then the two partial reports must be combined and entered in the Provider Portal.

New this year: OHCA has added several new cost fields for those ICF/IID facilities participating in the new Enhanced Payment for Vocational and Day Services Program. New Vocational Services Staff and Day Services Staff fields have been added to the Salary and Wages Schedule under the Vocational and Day Services (ICF ONLY) category. Located on the Outside Professional Fees schedule are fields for Vocational Services Staff (ICF ONLY) and Day Services Staff (ICF ONLY). On the Office Expenses schedule, you will find both Vocational Services Cost and Day Services Cost fields. Lastly, on the Other Expenses schedule, we have added both Other Vocational Cost and Other Day Services Cost fields.

Thank you for the services you provide to SoonerCare members.

Provider Types/Specialties: 27/270-279, 08/080-081 & 086

Denied dental claims due to age for HAP members ages 65-67, for normally covered dental services with a DOS of May 12, 2023, onward, should be resubmitted for possible payment. Members under HAP are covered for limited dental services through the age of 67 through Dec. 31, 2023. Effective Jan. 1, 2024, age coverage for HAP individuals will be through age 64. For procedure coverage by age, please see fee schedule.

Provider Types/Specialties: 08/086; 08/108; 27/270-279

In January, OHCA announced the selection of two dental contracted entities, otherwise known as dental benefit plans (DBPs), to execute the dental component of OHCA’s comprehensive delivery system reform called SoonerSelect.

The selected DBPs are DentaQuest and LIBERTY Dental Plan. DentaQuest and LIBERTY Dental Plan will begin administering the SoonerSelect dental program for most SoonerCare members on Feb. 1, 2024.

Refer to Provider Letter 2023-12 for additional information on current efforts underway by the selected DBPs to build their provider networks, as well as plan contact information for any questions on contracting and credentialing. 

Provider Types/Specialties: All

The SC-14 form that is used for administrative referrals has been updated. It can be found on the forms page of OHCA’s public website.

For retrospective administrative referrals, the fax number has been removed and replaced with an email address: ProviderServicesAdmins@okhca.org. 

For prospective administrative referrals, the fax number has changed. The new number is 405-213-1145.  

Provider Types/Specialties: All

The Oklahoma Health Care Authority (OHCA) and Unite Us have entered a partnership to aid OHCA SoonerCare members affected by the end of the public health emergency. OHCA and Unite Us are coordinating efforts to help members who are losing their Medicaid access to transition to other forms of health care. The referral process works through a shared technology platform, Unite Us, which enables OHCA to send electronic referrals to connect SoonerCare members to benefits navigation, address social care needs, and improve health across communities.

We know that each of you is a frontline provider to these members, and you will come into contact with them in situations where their benefits have lapsed and they need to connect to resources to address their medical care. To accomplish this, we are hosting an enablement session to introduce you to Unite Us, explain the process, and provide you with a simple and efficient way to help your patients in that moment.

The session will be held 2 p.m., Tuesday, July 11. Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.  

Provider types: 01, 02, 08, 09, 10, 31, 52,

Effective July 1, 2023, OHCA will require a prior authorization for certain surgical procedures provided to children ages 0-17.  These services have been identified as procedures that could be performed for gender affirmation; however, they could also be performed for other medically necessary indications.  The following procedure codes will require a PA for ages 0-17: 17999, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54690, 55175, 55180, 55899, 56805, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58700, 58720, 58953, 58956. Providers may refer to the AMA CPT manual for code descriptions.

Provider Types/Specialties: 16, 23, 24, 56

Oklahoma Health Care Authority will present a SoonerQuit webinar at 10 a.m., June 20. During this webinar, providers will familiarize themselves with services offered for the Diabetes Self-Management Education and Support (DSMES) and Medical Nutrition Therapy (MNT) benefits. Topics covered include Oklahoma diabetes statistics, diabetes and SoonerCare members, new web pages and materials, DSMES eligibility, enrollment, and billing codes for both services. This webinar will be of particular interest to provider types who can perform and bill for MNT and DSMES.

Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

TITLE: Nursing Facility Pay for Performance (PFP) Payment Update

Run Date: 5/31/2023–6/7/2023

PV Type:  03/30, 35

SFY2023 4th quarter PFP payment will be made on May 31, 2023

We thank you for your continued service to SoonerCare members.

Provider Types: 53 (Under Supervision)

The following contract expires May 31, 2023:  Behavioral Health Under Supervision. To avoid any delay in reimbursement, OHCA encourages providers to begin the renewal process as soon as possible. Visit the provider training page for a how-to video on renewing your SoonerCare contract. The video is located under the SoonerCare How-To Videos dropdown titled “Renewing your SoonerCare Contract.”

Providers unable to access the OHCA secure provider portal to submit a contract renewal must complete a PIN reset form. The global message dated March 19, 2021, provides instructions on how to complete the PIN reset form.

If you have any questions, please contact provider enrollment at 800-522-0114, option 5, or via email at providerenrollment@okhca.org.

Provider contracts will include language recommending a tobacco-free environment. Implementing a tobacco-free environment is beneficial to employees, patients and visitors as it supports the creation of a safe and healthy workplace, helps protect against second- and third-hand smoke exposure, and encourages people to quit. Generating awareness of this change through signage, decals and other means of communication is highly encouraged. If you need assistance with developing or updating a tobacco-free environment policy or obtaining signage, the SoonerQuit program can assist you with your specific needs. Please email the SoonerQuit team at SoonerQuit@okhca.org for more information.

Provider Types:  01, 08, 31, 52

C-section rate letters for the first six months (July-December) of state fiscal year 2022 are now available through the OHCA provider portal.

If you need help retrieving your letters, please call 800-522-0114.

You may also view the SoonerCare C-section rates and reports on the OHCA C-section page.

Thank you.

Provider Types/Specialties:  010, 014, 325, 326, 331.

Effective July 1, 2023, OHCA is adding PA requirement for CPT 22856 – Insertion of Artificial Spine Disc, Anterior Approach.

Providers: All

Effective April 18, 2023, OHCA has updated coverage for COVID-19 vaccine administration codes as follows:

• Addition of new COVID-19 bivalent vaccination administration codes 0121A, 0141A, 0142A, 0151A, 0171A and 0172A.
• Revision of codes 0124A, 0134A, 0144A, 0154A, 0164A, 0173A and 0174A to include replacing the term “booster” with “additional dose” for bivalent Pfizer and Moderna administration codes.
• Removal of COVID-19 monovalent administration and vaccine codes, 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A 91300, 91301, 91305, 91306, 91307, 91308, 91309, 91311, as they are no longer authorized by the FDA within the United States.

Code Descriptions:
0121A- Pfizer bivalent vaccine, single dose
0141A- Moderna bivalent vaccine, first dose
0142A- Moderna bivalent vaccine, second dose
0151A- Pfizer bivalent vaccine, single dose
0171A- Pfizer bivalent vaccine, first dose
0172A- Pfizer bivalent vaccine, second dose

Additional information can be found on the AMA website. 

Providers: All

Effective May 12, 2023, following the end of the public health emergency (PHE) that was declared in March 2020, OHCA will continue to allow certain services to be provided via telephone or other real-time, interactive, audio-only technology. Providers should adhere either modifier 93 or modifier FQ to show that services are performed using audio-only technology. A list of allowed audio-only service codes can be found on the OHCA Telehealth webpage.

Provider Types/Specialties: 03/030, 031, 034, 035

OHCA has recently made a change for new and renewing nursing facility contracts. Contracts will now require the Survey Document from OSDH (form #2567).  For questions, call Provider Enrollment at 800-522-0114, option 5.  

Provider Types/Specialties: 12/120

SFY 2023 Q3 invoices for the Oklahoma Health Care Authority state share billback has incorrect information in the expenditure field of the invoice, although the billed amount is the correct amount that is owed. If you require a corrected invoice in regards to the expenditure field you can email Tyler Mclemore at Tyler.Mclemore@okhca.org to request.

Provider Types/Specialties: 01/011,012,013,204,205,206; 03/030,031,033-037; 04/040; 05/050,051; 09/093,564; 10/100; 63/630,634.

Effective 5/11/2023: Videoconferencing for MI PASRR Level II will be allowed post-PHE under the following parameters:

1.     Must use the HIPAA compliant version of Zoom provided by the OU College of Nursing (OUCON). The evaluation will be scheduled by the evaluator and the link sent to the referring provider.

2.     If resource or geographic limitations necessitate, videoconferencing may be used when an evaluator is covering a region for another evaluator or completing a two-day emergency assessment.

3.     A face-to-face will be completed if the following limitations are present:

a.     The individual has an intellectual disability that will prevent a thorough comprehensive evaluation due to the individual’s limitations.

b.     The individual is unable to interact via videoconferencing due to medical or behavioral health limitations.

c.      When the individual receiving the PASRR evaluation does not consent to videoconferencing and prefers face-to-face.

d.     An evaluation is started via videoconferencing, and it is deemed by the evaluator that psychosis is present and the member is unable to complete the assessment, even though the member may be medically stable.

4.     Videoconferencing may be used if the nursing facility has an outbreak of any transmittable disease.

5.     Individuals receiving an evaluation must be medically stable and able to communicate with the evaluator (i.e., individuals on a ventilator or unresponsive due to their medical/mental health would not be clinically appropriate to complete the evaluation until medically stable).

6.     For assessments that require two hours of round-trip travel — from evaluation start to completion of evaluator’s final location — videoconferencing may be used.

7.     Telephonic evaluations should be used as a last resort if this is the only means of communication and, if due to a geographic or resource limitation, it would prevent the evaluation from being completed within 7 to 9 business days. The evaluation should only be completed with approval by OHCA and the Oklahoma Department of Mental Health and Substance Abuse Services.

OHCA Psych ID/analyst will request medical records (vitals, height, weight, history and physical, psychiatric records, hospital consults, medications, progress notes, name/contact for individual mental health provider, physician email address, and discharge summary) from the referring provider be sent to the OUCON fax number, 405-271-2626, for the MI PASRR Level II evaluation. This does not take the place of the OUCON face-to-face or videoconferencing evaluation. Medical records must be sent by close of business the day the PASRR Level II evaluation is requested. If medical records are not received by the next business day, the referring provider will need to reorder a Level II PASRR. 

For Resident Reviews: Mental Health Services provided for individual in the past year.

***Please do not send the “Screening for Level II PASRR” to the OUCON fax number. The “Screening for Level II PASRR” must be filled out by the referring provider including the member’s RID number (SoonerCare number if applicable) and faxed to OHCA at 405-708-7181. Any delays in completing this form completely could result in a delay with the evaluation.

Providers: All

Effective 5/12/23, OHCA will end the expanded use of telehealth as allowed during the public health emergency (PHE) that was declared in March 2020. OHCA will continue to allow services provided via telehealth for select medical and behavioral health services. A list of allowed telehealth services can be found at the following link: Telehealth (oklahoma.gov).  

Provider Types/Specialties: 05/050, 051; 06/060; 08/087, 193; 11/110, 111, 118; 17/170; 25/250; 26/260, 261; 28/280; 29/290, 291; 53

Dear Providers,

Due to the public health emergency (PHE) that stemmed from COVID-19, OHCA suspended our normal site visit procedure. As the PHE ends, we are required to resume our normal practice of conducting a site visit before a contract is approved.

Effective immediately, all contract types that require a site visit will be pended until the site visit has been completed and approved. Per federal requirement 42CFR §455.432, pre-enrollment site visits of providers who are designated as “moderate" or "high" categorical risks are required. The purpose is to verify that the information submitted to the Oklahoma Health Care Authority (OHCA) by a provider is accurate and to determine compliance with federal and state enrollment requirements. The site visit may be unannounced.

Upon arrival at the location, we will verify the physical address. If the location is closed, we will determine if the business appears to be operational. If so, we will make plans for another site visit and allow only one other opportunity for a successful site visit. If after two attempts at a site visit the OHCA representative is unable to make contact and tour the facility, a recommendation will be made to deny enrollment.

Provider Types/Specialties: 17/ 176-178

During this webinar from 10-11:30 a.m., Tuesday, April 18, providers will learn about ABA medical necessity criteria and prior authorization.

Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

All SoonerCare Providers

Due to COVID-19, Medicaid renewals were paused. However, Oklahoma will soon be required to restart eligibility reviews for all SoonerCare members, ineligible members will be disenrolled from SoonerCare over a period of 9 months, with some members losing eligibility effective 4-30-2023. 

For more information visit the Provider page https://oklahoma.gov/ohca/providers.html under resources you may view the document and video “Determining Member Eligibility”.

There will be a special enrollment period on the Affordable Care Act Marketplace for those who lose their Medicaid coverage due to the return of eligibility renewals. The special enrollment period will stretch from March 31, 2023, to July 31, 2024.

If you have a member who has questions about this process, please refer them to MySoonerCare.org where they can update their information and find an FAQ about this process. If they still have questions, they can also call the SoonerCare helpline at 800-987-7767. 

Because members will lose coverage in phases, it is important providers verify eligibility on the date of EVERY service and not use a date span.

Provider Types/Specialties: 01, 08, 09, 10, 31, 52

Effective April 1, 2023, OHCA will increase the limits for Osteopathic Manipulation Therapy codes 98925-98929 for adults from two (2) treatments per month to four (4) treatments per month. If more than four treatments per month are deemed necessary, a prior authorization override is allowed. There is no limit for medically necessary OMT therapy for children ages 0-20. 

Provider Types/Specialties: 08/208, 56/567

Effective March 2023, contracts with OHCA for Diabetic Educators will have a name change to Diabetes Educators. For questions or concerns regarding this change, contact OHCA Provider Enrollment at 800-522-0114 option 5. 

Provider Types/Specialties: 27/270-279, 08/080-081 & 086

The D7473 has been updated in our systems to reflect the correct quadrants per the ADA standards of quadrant listings of 30 and 40. If you have submitted a prior authorization using R, L or 02 that has been approved but the claim is not paying due to the quadrants listed, please contact the dental authorization unit at 405-522-7401. If you have an authorization recently submitted and approved using R, L or 02, please select to amend the lines of the prior authorization approval and request the correct quadrants according to the ADA.

Provider types: 08, 09, 10,13, 16, 31, 52

The Focus Forward Oklahoma Program is working to address issues related to access and utilization of long-acting reversible contraceptives (LARC).

Focus Forward Oklahoma offers no-cost LARC training to Oklahoma providers, clinical support staff and administrative staff. For more information about Focus Forward and available training visit http://focusforwardok.org/.

Provider Types/Specialties: 09, 10, 14, 15, 17, 18, 20, 23, 31, 52, 53, 57

OHCA is asking rendering providers to complete a survey about their experience with SoonerCare. The postcard with a link to the survey is in the mail. Surveys are due by April 28.

Your feedback is invaluable, and we are committed to using it to improve your experience and help you serve SoonerCare members.

Provider Types: 08, 09, 10, 31, 52

Effective immediately, professional claims with place of service 22 (outpatient) will no longer require referrals from the primary care physician. 

Provider Types/Specialties: 17/ 176-178

During this webinar from 2-3:30 p.m., Thursday, March 30, providers will familiarize themselves with an overview of ABA medical necessity criteria and prior authorization.

Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Provider Types: 08, 09, 10, 31, 52

Effective for dates of service beginning March 1, 2023, OHCA will begin reimbursing for an evaluation and management service in addition to an Early Periodic Screening, Diagnosis and Treatment (EPSDT) screening for children ages 0-20 when appropriate. The EPSDT screening is still considered a comprehensive examination. However, if a member is receiving an EPSDT screening and an additional focused complaint arises that requires additional evaluation and management to address the complaint, the provider may deliver all medically necessary care and submit a claim for both the EPSDT screening and the appropriate level of focused service if the following requirements are met:

• The medical issue is significant enough to require additional work to address the issue.
• The visit is documented on a separate note.
• There is appropriate documentation that clearly lists the condition being managed at the time of the encounter and supports the billing of both services.
• Modifier 25 is added to the appropriate code that indicates that a separate evaluation and management service was provided by the same physician on the same day as the EPSDT screening. All claims submitted with Modifier 25 will be reviewed prior to payment.
• The following items will be reviewed prior to any payment:
  • Medical necessity.
  • Appropriate utilization of Modifier 25.
  • Appropriate level of service billed.
  • All documentation to support both the EPSDT screening and the additional evaluation and management for a focused complaint must be submitted for review.

When providing evaluation and management of a focused complaint during an EPSDT screening, the provider may claim only the additional time that is required above and beyond the completion of the comprehensive EPSDT screening.

An insignificant or trivial problem that is encountered in the process of performing the preventive evaluation and management service and does not require additional work is included in the EPSDT visit and should not be billed/reported.

Additional information regarding EPSDT visits can be found in OHCA Policy PART 4. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program/Child Health Services (oklahoma.gov).

PV Type:  03/30, 35

SFY 2023 Third Quarter PFP payment will be made on Feb. 22, 2023.

We thank you for your continued service to SoonerCare members.

PV Types:    01, 08, 31, 52

The year-end C-section rate letters for state fiscal year 2022 are now available through the OHCA Provider Portal. As a reminder, these C-section letters are now only available electronically.

If you need help to retrieve your letters, please call 800-522-0114.

You may also view the C-section rate release schedule on the OHCA webpage at www.okhca.org/c-section.

Thank you.

Provider Types/Specialties: All

During this webinar from 2-3:30 p.m., Thursday, Feb. 16, providers will familiarize themselves with an overview of OHCA’s Third Party Liability and HMS process.

Visit the OHCA Provider Training page to register. You will receive a confirmation email with information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.

Target Audience: Eye Care Providers

Each year, Oklahoma Health Care Authority performs a random sample audit of SoonerCare claims. This year’s review showed a higher-than-normal error based on the eye care provider maintaining records that document the SoonerCare member having received, picked up, being fitted, or being delivered frames, lenses, etc. 

As a reminder, please have the member or representative sign for the eyewear and maintain medical records for a minimum of six years per OAC 317:30-3-15. Record retention.

Providers: 27/270-279, 08/080-081 & 086

The Oklahoma Healthcare Authority has recently undergone a fee adjustment that was set with the effective date of Oct. 1, 2022. Claims filed from that date forward undergo claims recycle that is in progress. Per policy, providers are required to indicate their usual and customary charge when submitting claims. Providers who bill the SoonerCare allowable fee are advised to void and refile their claims from date of service Oct. 1, 2022 forward with their fees per policy. Please see Usual and Customary fee policy found at 317:30-3-5.1. Usual and Customary fees (oklahoma.gov)

Providers: Hospital (01), Clinic (08), Advance Practice Nurse (09), Mid-Level Practitioner (10), Laboratory (28), Physician (31), State Employed Physicians (52)

In May 2022, OHCA made updates in the MMIS claim system to change modifier 90 (reference [outside] laboratory) from an informational modifier to a denial modifier. OHCA has now set modifier 90 back to be an informational-only modifier, effective May 12, 2022.  Providers who received denials for claims lines where modifier 90 was applied may now refile those claims, if appropriate. Timely filing rules will apply. 

Providers: All

OHCA has updated coverage for laboratory testing of infectious diseases using molecular testing (CPT 87471-87801) effective Jan. 1, 2023. Providers will find the updated coverage guidelines on the Medical Authorization Unit’s webpage.

Changes include reopening coverage for CPT code 87634 (RSV) and 87637 (COVID-19, Flu A&B, and RSV) when performed by hospital labs, independent labs or clinic labs for symptomatic individuals who are immunocompromised, have chronic respiratory illness or influenza complicated by pneumonia, or who are pregnant.  

Target Audience: Licensed Oklahoma Providers and Organizations

OHCA will present a webinar titled Improving Care Coordination, Delivery, and Quality Utilizing Oklahoma’s Health Information Exchange at 12 p.m., Thursday, January 26. This webinar will provide the details of recent legislation regarding participation in Oklahoma’s state-designated Health Information Exchange (HIE), review the capabilities and benefits of utilizing the HIE to provide care and services, and discuss the process for joining and getting connected to the HIE.

Presenters:
Stephen W. Miller, CHCIO (State Coordinator for Health Information Exchange)
David C. Kendrick, MD, MPH (CEO, MyHealth Access Network)

Visit the OHCA Provider Training page to register.

After registering, you will receive a confirmation email containing information about joining the webinar and reminder emails before the webinar begins. Registrants unable to attend the webinar session should notify SoonerCareEducation@okhca.org to cancel their registration.