Library: Policy
340:75-16-37. Child who no longer meets medical necessity criteria for inpatient behavioral health treatment
Revised 9-15-16
When the Oklahoma Health Care Authority or its designated agent determines a child in Oklahoma Department of Human Services custody no longer meets medical necessity criteria for inpatient behavioral health services and when the attending physician agrees to discharge, the child is discharged and placed in an appropriate placement with consideration of the inpatient behavioral health services staff's recommendation. • 1 through 3
INSTRUCTIONS TO STAFF 340:75-16-37
Revised 9-15-16
1.KIDS placement recommendation.The assigned child welfare (CW) specialist enters a placement recommendation on the KIDS Placement screen and obtains supervisor approval.
2.Reconsideration request for inpatient treatment procedures are outlined in Oklahoma Administrative Code (OAC) 340:75-16-32.
3.(a) Reconsideration request for inpatient behavioral health services denial.A request for reconsideration of the decision of the Oklahoma Health Care Authority (OHCA) or its designated agent for the child in Oklahoma Department of Human Services custody who is denied continued inpatient behavioral health services or no longer meets medical necessity criteria for inpatient behavioral health services, but the therapist or physician does not agree to the child's discharge.The assigned CW specialist or inpatient facility immediately contacts OHCA or its designated agent for reconsideration when the denial is based on incomplete data, and the assigned CW specialist or the inpatient facility staff has additional information that may warrant continued admission for inpatient behavioral health services.
(b) Reconsideration request upheld.When OHCA or its designated agent upholds the reconsideration request, the child remains inpatient.
(c) Reconsideration request denied.When OHCA or its designated agent denies the reconsideration request, the assigned CW specialist may request through the district attorney a court order, with notice to the child's attorney, ordering the child to remain in the specific facility for continued inpatient behavioral health services.
(1) When the court agrees to continued inpatient behavioral health services, the child remains inpatient until the court rules the child no longer requires inpatient treatment.A copy of the court order is faxed to Child Welfare Services Specialized Placements and Partnerships Unit administration.
(2) When the court does not agree to continued inpatient behavioral health services, the assigned CW specialist arranges placement, considering the therapist's or physician's recommendation that the child remain inpatient even though the child no longer meets medical necessity criteria.
(3) When the denial is upheld, the denial may be appealed to OHCA within 20-business days of the initial decision by OHCA or its designated agent.OHCA has the final authority on the decision.
