Library: Policy

317:30-5-211.3. Prior authorization (PA)

Revised 9-12-22

(a) General. PA is the electronic or written authorization issued by the Oklahoma Health Care Authority (OHCA) to a provider prior to the provision of a service. Providers should obtain a PA before providing services.

(b) Requirements. Billing must follow correct coding guidelines as promulgated by the Centers for Medicare and Medicaid Services (CMS) or per uniquely and publicly promulgated OHCA guidelines. Medical supplies, equipment, and appliances claims must include the most appropriate Healthcare Common Procedure Coding System (HCPCS) code as assigned by the Medicare Pricing, Data, Analysis, and Coding (PDAC) or its successor. Authorizations for services not properly coded will be denied. The following services require PA:

(1) Services that exceed quantity/frequency limits;

(2) Medical need for an item that is beyond OHCA's standards of coverage;

(3) Use of a Not Otherwise Classified (NOC) code or miscellaneous codes;

(4) Services for which a less costly alternative may exist; and

(5) Procedures indicating that a PA is required on the OHCA fee schedule.

(1) PA requirements. Requirements vary for different types of services. Providers should refer to the service-specific sections of policy or the OHCA website for services requiring a PA. Also refer to OAC 317:30-3-31.

(A) Required forms. All required forms are available on the OHCA website.

(B) Certificate of medical necessity (CMN). The prescribing physician, non-physician practitioner (NPP), or dentist must complete the medical necessity section of the CMN. This section cannot be completed by the supplier. The medical necessity section can be completed by any health care clinician; however, only the member's physician, NPP, or dentist may sign the CMN. By signing the CMN, the physician, NPP, or dentist is validating the completeness and accuracy of the medical necessity section. The member's medical records must contain documentation substantiating that the member's condition meets the coverage criteria and the answers given in the medical necessity section of the CMN. These records may be requested by OHCA or its representatives to confirm concurrence between the medical records and the information submitted with the PA request.

(2) Submitting PA requests. Contact information for submitting PA requests may be found in the OHCA Provider Billing and Procedures Manual. An electronic version of this manual is located on the OHCA website.

(3) PA review. Upon verifying the completeness and accuracy of clerical items, the PA request is reviewed by OHCA staff to evaluate whether or not each service being requested meets SoonerCare's definition of "medical necessity" [see OAC 317:30-3-1 (f)] as well as other criteria.

(4) PA decisions. After the PA request is processed, a notice will be issued regarding the outcome of the review.

(5) PA does not guarantee reimbursement. Provider status, member eligibility, and medical status on the date of service, as well as all other SoonerCare requirements, must be met before the claim is reimbursed.

(6) PA of manually-priced items. Manually-priced items must be prior authorized. For reimbursement of manually priced items, see OAC 317:30-5-218.