Library: Policy

317:30-5-111. Coverage for adults

Revised 10-1-07

       For persons 21 years of age or older, payment is made to hospitals for inpatient services as described in this section.

• (1) All general inpatient hospital services which are not provided under the Diagnosis Related Group (DRG) payment methodology for all persons 21 years of age or older is limited to 24 days per person per state fiscal year (July 1 through June 30).  The 24 day limitation applies to both hospital and physician services.  No exceptions or extensions will be made to the 24 day inpatient services limitation.

• (2) All inpatient stays are subject to post-payment utilization review by the OHCA's designated Quality Improvement Organization (QIO).  These reviews are based on  severity of illness and intensity of treatment.

  • (A) It is the policy and intent of OHCA to allow hospitals and physicians the opportunity to present any and all documentation available to support the medical necessity of an admission and/or extended stay of a SoonerCare member.  If the QIO, upon their initial review determines the admission should be denied, a notice is issued to the facility and the attending physician advising them of the decision.  This notice also advises that a reconsideration request may be submitted within the specified time frame on the notice and consistent with the Medicare guidelines.  Additional information submitted with the reconsideration request is reviewed by the QIO that utilizes an independent physician advisor.  If the denial decision is upheld through this review of additional information, the QIO sends written notification of the denial decision to the hospital, attending physician and the OHCA.  Once the OHCA has been notified, the overpayment is processed as per the final denial determination.

  • (B) If the hospital or attending physician did not request reconsideration from the QIO, the QIO informs OHCA there has been no request for reconsideration and as a result their initial denial decision is final.  OHCA, in turn, processes the overpayment as per the denial notice sent to the OHCA by the QIO.

  • (C) If an OHCA, or its designated agent, review results in denial and the denial is upheld throughout the appeal process and refund from the hospital and physician is required, the member cannot be billed for the denied services.

• (3) If a hospital or physician believes that a hospital admission or continued stay is not medically necessary and thus not compensable but the member insists on treatment, the member should be informed that he/she will be personally responsible for all charges.  If a claim is filed and paid and the service is later denied, the patient is not responsible.

• (4) Payment is made to a participating hospital for hospital based physician's services.  The hospital must have a Hospital-Based Physician's contract with OHCA for this method of billing.

• (5) Outpatient services for adults are covered as listed in OAC 317:30-5-42.1.