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Library: Policy

317:30-3-14. Freedom of choice

Revised 9-1-15

(a) Any Qualified provider.  The Oklahoma Health Care Authority (OHCA) assures that any individual eligible for SoonerCare, may obtain services from any institution, agency, pharmacy, person, or organization that is contracted with OHCA and qualified to perform the services.

(b) Member lock-in.  SoonerCare members who have demonstrated utilization above the statistical norm, during a 6-month period, may be "locked-in" to a prescriber and/or one pharmacy for medications classified as controlled dangerous substances in accordance with Federal Regulation 42 CFR 431.54.

(1) Over-utilization patterns by SoonerCare members may be identified either by referral or by OHCA automated computer systems.  SoonerCare records, for a 6-month period, of those identified members are then reviewed. Medical and pharmacy claim histories are reviewed by OHCA pharmacy consultants to determine if high usage is medically justified.

(2) If it is determined that SoonerCare has been over-utilized, the member may be notified, by letter, of the need to select a prescriber and/or pharmacy and of their opportunity for a fair hearing.  If they do not select a prescriber or pharmacy, one is selected for them. In some cases, members may be sanctioned under OAC 317:35-13-7.

(3) The prescriber and/or pharmacy of choice, unless the aforementioned providers have been identified as having problems with over-utilization, are notified by letter and given an opportunity to accept or decline to be the member's prescriber and/or pharmacy.

(4) When the provider accepts, a confirmation letter is sent to both member and provider showing the effective date of the arrangement.

(5) After the lock-in arrangement is made, the provider may file claims for services provided in accordance with OHCA guidelines.

(6) Locked-in members may obtain emergency services from an emergency room facility for an emergency medical condition or as part of an inpatient admission.

(7) If a claim for a controlled dangerous substance is filed by another pharmacy, the claim will be denied.

(8) When a member is enrolled into the lock-in program, usage is monitored periodically and reviewed every 24 months.  A provider may send a written request for member review.  If review indicates utilization patterns meet lock-in removal criteria, the member may be removed from lock-in at the discretion of OHCA staff.

(9) During a review, OHCA may elect to continue lock-in, remove the member from lock-in because of medical necessity, remove them because of decreased utilization, or impose sanctions under OAC 317:35-13-7.

(10) The member in the lock-in program may make a request to change providers after the initial three months; when the member moves to a different city or if the member feels irreconcilable differences will prevent necessary medical care.  Change of providers based on irreconcilable differences must be approved by OHCA staff or contractor.

(11) OHCA may make a provider change when the provider makes a request for change or may initiate a change anytime it is determined necessary to meet program goals.

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