(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.
(1) "Assistive technology professional" or "ATP" means a for-service provider who is involved in analysis of the needs and training of a consumer in the use of a particular assistive technology device or is involved in the sale and service of rehabilitation equipment or commercially available assistive technology products and devices. All ATPs are required to be credentialed by Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
(2) "Custom seating system" means a wheelchair seating system which is individually made for a member using a plaster model of the member, a computer-generated model of the member (e.g., CAD-CAM technology), or the detailed measurements of the member to create either:
(A) A molded, contoured, or carved (foam or other suitable material) custom-fabricated seating system that is incorporated into the wheelchair base; or
(B) A custom seating system made from multiple pre-fabricated components or a combination of custom fabricated materials and pre-fabricated components which have been configured and attached to the wheelchair base or incorporated into a wheelchair seat and/or back in a manner that the wheelchair could not be easily re-adapted for use by another individual.
(3) "Specialty evaluation" means the determination and documentation of the consumer's pathology, history and prognosis, and the physiological, functional, and environmental factors that impact the selection of an appropriate wheeled mobility system.
(b) Medical Necessity. Medical necessity, pursuant to Oklahoma Administrative Code (OAC) 317:30-5-211.2, is required for a wheelchair to be covered and reimbursed by SoonerCare. Only one (1) wheelchair is covered as medically necessary during its reasonable useful lifetime, unless the member's documented medical condition indicates the current wheelchair no longer meets the member's medical need. Backup wheelchairs are not covered items.
(c) Prior authorization. Prior authorization, pursuant to OAC 317:30-5-211.3, is required for selected wheelchairs to be covered and reimbursed by SoonerCare. All prior authorization requests for the purchase of a wheelchair must indicate the length of the warranty period and what is covered under the warranty.
(1) Wheelchairs, wheelchair parts and accessories, and wheelchair modifications that are beneficial primarily in allowing the member to perform leisure or recreational activities are not considered medically necessary and will not be authorized.
(2) Wheelchair parts, accessories, and/or modifications that are distinctly and separately requested and priced from the original wheelchair request may require prior authorization.
(3) The Oklahoma Health Care Authority will deny prior authorization requests when the required forms have not been fully completed or the member's medical record does not provide sufficient information to establish medical necessity or to determine that the criteria for coverage has been met.
(d) Coverage and limitations. For members who reside in a long-term care facility or intermediate care facility for individuals with intellectual disabilities, all standard manual and power wheelchairs are considered part of the facility's per diem rate. Repairs and maintenance for wheelchairs are considered part of the facility's per diem rate.
(1) The specialty evaluation or wheelchair selection documentation must be submitted with the prior authorization request.
(2) The specialty evaluation or wheelchair selection must be performed no longer than ninety (90) days prior to the submission of the prior authorization request.
(3) The results of the specialty evaluation or wheelchair selection documentation must be supported by the information submitted on the member's medical record.
(4) A copy of the dated and signed written specialty evaluation or wheelchair selection document must be maintained by the wheelchair provider. The results of the specialty evaluation or wheelchair selection must be written, signed, and dated by the medical professional who evaluated the member or the ATP who was involved in the wheelchair selection for the member.