Library: Policy

317:30-5-25. Oklahoma Health Care Authority's Quality Improvement Organization (QIO)

Revised 8-2-06

     All inpatient stays and outpatient observation services are subject to post-payment utilization review by the OHCA's designated Quality Improvement Organization (QIO).  These reviews are based on severity of illness and intensity of treatment.

• (1) It is the policy and intent of OHCA to allow hospitals and physicians the opportunity to present any and all documentation available to support the medical necessity of an admission and/or extended stay or outpatient observation of a SoonerCare member.  If the QIO, upon their initial review determines the admission or outpatient observation services should be denied, a notice is issued to the facility and the attending physician advising them of the decision.  This notice also advises that a reconsideration request may be submitted within the specified timeframe on the notice and consistent with the Medicare guidelines.  Additional information submitted with the reconsideration request is reviewed by the QIO that utilizes an independent physician advisor.  If the denial decision is upheld through this review of additional information, the QIO sends written notification of the denial decision to the hospital, attending physician and the OHCA.  Once the OHCA has been notified, the overpayment is processed as per the final denial determination.

• (2) If the hospital or attending physician did not request reconsideration from the QIO, the QIO informs OHCA there has been no request for reconsideration and as a result their initial denial decision is final.  OHCA, in turn, processes the overpayment as per the denial notice sent to the OHCA by the QIO.

• (3) If the QIO's review results in denial and the denial is upheld throughout the review process and refund from the hospital and physician is required, the SoonerCare member cannot be billed for the denied services.

• (4) If a hospital or physician believes a hospital admission, continued stay, or outpatient observation service is not medically necessary and thus not SoonerCare compensable but the member insists on treatment, the member is informed that he/she will be personally responsible for all charges.

• (A) If a SoonerCare claim is filed and paid and the service is later denied after medical necessity review, the member is not responsible.

• (B) If a SoonerCare claim is not filed, the member can be billed.