Library: Policy

317:30-5-621. Coverage by category

Revised 6-11-99

     Payment is made for early intervention case management services as set forth in this Section.

• (1) Adults.  There is no coverage.
• (2) Children.  Coverage for children (age o to age 3) is as follows:
  • (A) Description.
    • (i) Services under case management are not comparable in amount, duration and scope.  The target group for case management services are developmentally disabled infants and toddlers (ages 0-3) who are eligible for early intervention services under Oklahoma's implementation plan to meet provisions of the Individuals with Disabilities Education Act(IDEA), Amendments of 1997.
    • (ii) Case management refers to services provided to assist a client in gaining access to needed medical, social, educational and other services essential to meeting basic human needs.  Case management may include, but is not limited to:
      • (I) referral, coordination and linkage to needed services;
      • (II) arranging for service delivery to ensure access to needed services;
      • (III) monitoring and follow-up of client's activities to insure access, quality and delivery of needed services; and
      • (IV) preparation of case record documentation documenting the above activities.
  • (B) Non-Duplication of services.  To the extent any eligible recipients in the identified targeted population are receiving TCM services from another provider agency, as a result of being  members of other covered targeted groups, the providers assure that case management activities are coordinated to avoid unnecessary duplication of service.  To the extent any of the services required by the client are a Medicaid covered benefit of a managed care organization of which the client is a member, the provider will assure that timely referrals are made and that coordination of care occurs.  Case management services shall be directed through a case manager who is an individual solely dedicated to that function.  OHCA reimbursement will require that case managers may not provide clinical services and clinical staff may not provide case management services.
  • (C) Providers.  Case management services must be provided by a qualifying provider of early intervention case management as certified by the State Department of Education, pursuant to the requirements of the Individuals with Disabilities Education Act, Amendments of 1997.
• (3) Special Health Care Needs program.  For children who are not eligible for Medicaid, and the application has been approved for Special Health Care Needs services through the Oklahoma Department of Human Services, a request for prior authorization for services must be submitted to the Medical Authorization Unit of OHCA for review and approval.
• (4) Individuals eligible for Part B of Medicare.  Case Management Services provided to Medicare eligible recipients should be filed directly with the fiscal agent.