Library: Policy

317:30-5-1012. Reimbursement

Revised 6-25-12

(a) Reimbursement for DDSDTCM services is a unit rate based on the weekly cost per case for documented DDSDTCM services. The cost base consists of the annualized cost of case management staff including all applicable overhead and indirect service cost in accordance with the approved DHS cost allocation plan. A first year interim rate is computed by dividing the annual cost base by the projected number of units. Subsequent annual rates will include an adjustment based on previous years cost versus total billable amount. A unit of service is defined as one calendar week of targeted case management, provided that a minimum of one contact which meets the description of a targeted case management activity with or on behalf of the member has been documented during the week claimed. Payment is made on the basis of claims submitted for payment. The provider bills at the weekly unit rate for a documented unit of SoonerCare DDSDTCM services provided to each SoonerCare eligible member during the calendar week.

(b) Only one unit of DDSDTCM services may be billed for each SoonerCare eligible member per week while the member is receiving services under a DHS/DDSD HCBS Waiver or is in the transition process to receive those services. No more than twenty-six units of DDSDTCM may be provided and billed for each eligible SoonerCare member during their transition period from the institution. DHS/DDSD must provide documentation of all such transitional DDSDTCM services provided, indicating the date performed for each unit billed. In no case may DHS/DDSD bill for transitional and regular DDSDTCM services provided during the same week (i.e., if DDSD bills transitional DDSDTCM for the third week in June and the member is deinstitutionalized into the particular Waiver during the third week in June, DDSD cannot also bill for regular DDSDTCM for the third week in June). If DDSDTCM has been provided to an individual during such a transitional period but that individual dies before the placement into the community is made, decides to refuse the placement or the placement falls through, reimbursement is available.