Library: Policy

317:25-7-6. Primary Care Provider/Case Manager Payment to Subcontractors

Revised 6-25-04

(a) Under the provisions of the SoonerCare Contract, the contractor is responsible for providing all capitated services contained in the benefit package.  In the event that the PCP/CM orders a capitated service, the PCP/CM is responsible to make timely payment to the subcontractor or other provider.

(b) For purposes of subsection (a) of this Section timely payment or adjudication means payment or denial of a claim within 30 days of presentation to the PCP/CM.

(c) No subcontractor of the PCP/CM may charge more than the Medicaid fee-for-service schedule for these services in the benefit package.  The subcontractor may not bill the recipient for the services to the SoonerCare recipient until the PCP/CM has refused payment and the subcontractor/medical provider has appealed under OAC 317:2-1-2.1 and the OHCA permits the subcontractor to bill the recipient.