Library: Policy

317:25-7-40. SoonerCare Choice reimbursement

Issued 9-14-20

(a) Care coordination component.Participating primary care providers (PCPs) are paid a monthly care coordination payment to assure the delivery of medically-necessary preventive and primary care medical services, including referrals for specialty services for an enrolled group of eligible members. The PCP assists the member in gaining access to the health care system and monitors the member's condition, health care needs and service delivery.

(b) Visit-based fee-for-service component.SoonerCare Choice covered services provided by a PCP are reimbursed at the SoonerCare fee schedule rate under the procedure code established for each individual service.To the extent services are authorized by a PCP, the Oklahoma Health Care Authority (OHCA) does not make SoonerCare Choice payments for services delivered outside the scope of coverage of the SoonerCare Choice program. In other words, a referral by a PCP does not guarantee payment.

(c) Incentive program component.Subject to the availability of funds, OHCA will develop a bonus payment program to encourage coordination of services, to reward improvement in health outcome and promote efficiency.

(d) SoonerCare networks.For every PCP who participates in an OHCA approved Health Access Network, a per-member-per-month payment is established by OHCA and paid to the network.