Library: Policy

317:30-5-1090. Provision of other health services outside of the I/T/U encounter

Revised 09-12-22

(a) Medically necessary SoonerCare covered services that are not included in the I/T/U outpatient encounter rate may be billed outside the encounter rate within the scope of the SoonerCare fee-for-service (FFS) contract. The services will be reimbursed at the FFS rate, and will be subject to any limitations, restrictions, or prior authorization requirements. Examples of these services include, but are not limited to:

(1) Durable medical equipment [refer to Oklahoma Administrative Code (OAC) 317:30-5-210];

(2) Eyeglasses (refer to OAC 317:30-5-431, 317:30-5-432.1 and 317:30-5-451);

(3) Transportation by ambulance (refer to OAC 317:30-5-335);

(4) Home health (refer to OAC 317:30-5-546);

(5) Inpatient practitioner services (refer to OAC 317:30-5-1100);

(6) Non-emergency transportation (refer to OAC 317:30-5-326 through 317:30-5-327.9);

(7) Behavioral health case management (refer to OAC 317:30-5-241.6);

(8) Psychosocial rehabilitative services (refer to OAC 317:30-5-241.3);

(9) Psychiatric residential treatment facility services (refer to OAC 317:30-5-95 through 317:30-5-97);

(10) Applied behavior analysis (ABA) (refer to OAC 317:30-5-310 through 317:30-5-316); and

(11) Diabetes self-management education and support (DSMES) (refer to OAC 317:30-5-1080 through 317:30-5-1084).

(b) If the I/T/U facility chooses to provide other Oklahoma Medicaid State Plan covered health services which are not included in the I/T/U encounter definition, those service providers must be contracted with the Oklahoma Health Care Authority (OHCA) and bill for those services under their assigned provider number consistent with program coverage limitations and billing procedures described by the OHCA.

(c) Providers may bill for antepartum and postpartum visits, and a cesarean or vaginal delivery as individual encounters, or a provider can bill the packaged/bundled rate for total obstetrical care (OB) (which includes antepartum/postpartum visits and delivery). Providers may not bill for both antepartum/postpartum visits and a packaged/bundled rate for total OB care for the same episode of care. Refer to OAC 317:30-5-22 for more detailed obstetrical care policy.