317:30-5-327.6. Denial of SoonerRide NEMT services by the SoonerRide broker
(a) In addition to the exclusions listed in Oklahoma Administrative Code (OAC) 317:30-5-327.1 (f) (1) B (4) of this Part, the SoonerRide NEMT broker may deny NEMT services if:
(1) The long-term care facility/member refuses to cooperate in determining the member's eligibility;
(2) The long-term care facility/member refuses to provide the documentation required to determine the medical necessity for NEMT services;
(3) The member, medical escort, attendant, or service animal exhibits uncooperative behavior or misuses/abuses NEMT services;
(4) The member is not ready to board the NEMT transport at the scheduled time or within fifteen (15) minutes after the scheduled pick up time;
(5) The member has not shown or cancelled previous appointments less than twenty-four (24) hours prior to the appointment, or has cancelled three (3) times within a ninety (90) day period, upon the SoonerRide NEMT transport's arrival at the member's residence; or
(6) The long-term care facility/member fails to request a reservation at least three (3) days in advance of a health care appointment without good cause. Good cause is created by factors such as, but not limited to, any of the following:
(A) Urgent care;
(B) Post-surgical and/or medical follow up care specified by a health care provider to occur in fewer than three (3) days;
(C) Imminent availability of an appointment with a specialist when the next available appointment would require a delay of two (2) weeks or more; and
(D) The result of administrative or technical delay caused by SoonerRide and requiring that an appointment be rescheduled.
(7) All requests, provided with or without good cause, are subject to availability and resources.
(b) Pursuant to Federal law, SoonerRide will provide notification in writing to long-term care facilities/members when services have been denied. This notification must include the specific reason for the denial and the member's right to appeal.
(1) An appeal must be filed with the Oklahoma Health Care Authority (OHCA) in accordance with OAC 317:2-1-2.
(2) The appropriateness of transportation may be appealed only to the extent that the transportation does not meet the medical needs of the member. Dissatisfaction with the use of public transportation, shared rides, type of vehicle, etc., is not appropriate grounds for appeal.
(3) The OHCA's decision is final. This decision may be appealed to the chief executive officer of the OHCA pursuant to OAC 317:2-1-13.
(c) The agency contracts directly with ambulance and air providers for all other transportation needs for eligible members not approved by SoonerRide NEMT. Please refer to Subchapter 5, Part 33, Transportation by Ambulance, of this Chapter.