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Library: Policy

317:30-5-586.1. Prior authorization

Revised 7-1-07

(a) Prior authorization of behavioral health services and requirements to be authorized to provide case management services are mandatory.  The provider must request prior authorization from the OHCA or its designated agent.  In order for the services to be prior authorized, member information requested must be submitted.  Member information includes but is not limited to the following:

  • (1) Complete multi-axial DSM IV diagnosis with supportive documentation and mental status examination summary; and

  • (2) Treatment history; and

  • (3) Current psychiatric social information; and

  • (4) Psychiatric history; and

  • (5) Fully developed case management service plan, with goals, objectives, and time frames for services.

(b) SoonerCare members will be considered for prior authorization after receipt of complete and appropriate information submitted by the provider.  Based on diagnosis, functional assessment, history and other SoonerCare services being received, the SoonerCare member may be approved to receive case management services.  SoonerCare members who reside in nursing facilities, residential behavior management services, group or foster homes, or ICF/MR's may not receive SoonerCare compensable case management services.  A SoonerCare member may be approved for a time frame of one to six months.  The OHCA or its designated agent will review the request in accordance with the guidelines for prior authorization in the Outpatient Behavioral Health Provider Manual.  Requests will be reviewed by licensed behavioral health professionals under OAC 317:30-5-240.

(c) A prior authorization decision may be appealed by the member if filed within 20 days of receipt of the decision.  Until July 1, 2006, a provider may request a reconsideration from OHCA's designated agent within five working days of receipt of the decision.  The designated agent's decision regarding a reconsideration requests is final.

(d) Providers seeking prior authorization will follow OHCA's designated agent's Outpatient Behavioral Health Prior Authorization Manual guidelines for submitting requests on behalf of the SoonerCare member.

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