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Library: Policy

317:30-5-96.2. Payment definitions

Revised 9-14-20

     The following words and terms, when used in Sections OAC 317:30-5-96.3 through 317:30-5-96.7, shall have the following meaning, unless the context clearly indicates otherwise:

     "Allowable costs" means costs necessary for the efficient delivery of member care.

     "Ancillary Services" means the services for which charges are customarily made in addition to routine services. Ancillary services include, but are not limited to, physical therapy, speech therapy, laboratory, radiology and prescription drugs.

     "Border Status" means a placement in a state that does not border Oklahoma but agrees to the same terms and conditions of instate or border facilities.

     "Developmentally disabled child" means a child with deficits in adaptive behavior originating during the developmental period.  This condition may exist concurrently with a significantly subaverage general intellectual functioning.

     "Eating Disorders Programs" means acute or intensive residential behavioral, psychiatric and medical services provided in a discreet unit to individuals experiencing an eating disorder.

     "Professional services" means services of a physician, psychologist or dentist legally authorized to practice medicine and/or surgery by the state in which the function is performed.

     "Psychiatric Residential Treatment Facility (PRTF)" means a non-hospital with an agreement to provide inpatient psychiatric services to individuals under the age of 21.

     "Routine Services" means services that are considered routine in the freestanding PRTF setting. Routine services include, but are not limited to:

    • (A) room and board;

    • (B) treatment program components;

    • (C) psychiatric treatment;

    • (D) professional consultation;

    • (E) medical management;

    • (F) crisis intervention;

    • (G) transportation;

    • (H) rehabilitative services;

    • (I) case management;

    • (J) interpreter services (if applicable);

    • (K) routine health care for individuals in good physical health; and

    • (L) laboratory services for a substance abuse/detoxification program.

      "Specialty treatment program/specialty unit" means acute or intensive residential behavioral, psychiatric and medical services that provide care to a population with a special need or issues such as developmentally disabled, intellectually disabled, autistic/Asperger's, eating disorders, sexual offenders, or reactive attachment disorders.  These members require a higher level of care and staffing ratio than a standard PRTF and typically have multiple problems.

      "Treatment Program Components" means therapies, activities of daily living and rehabilitative services furnished by physician/psychologist or other licensed mental health professionals.

     "Usual and customary charges" refers to the uniform charges listed in a provider's established charge schedule which is in effect and applied consistently to most members and recognized for program reimbursement.  To be considered "customary" for reimbursement, a provider's charges for like services must be imposed on most members regardless of the type of member treated or the party responsible for payment of such services.

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