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317:30-5-110.Eligible providers
[Issued 10-3-05]
To be eligible for reimbursement, all licensed rehabilitation hospitals must be Medicare certified and have a current contract on file with the Oklahoma Health Care Authority (OHCA).

317:30-5-111.Coverage for adults
[Revised 09-14-2020]

For persons twenty-one (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 twenty-one (21) years of age or older is limited to ninety (90) days per person per state fiscal year (July 1 through June 30).  The ninety (90) day limitation applies to both hospital and physician services.  No exceptions or extensions will be made to the ninety (90) day inpatient services limitation.

(2) All inpatient stays are subject to post-payment utilization review by the Oklahoma Health Care Authority's (OHCA) 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 Oklahoma Administrative Code 317:30-5-42.1.

317:30-5-112.Coverage for children
[Issued 10-3-05]
Payment is made to rehabilitation hospitals for medical services for persons under the age of 21 within the scope of the Authority's Medical Programs, provided the services are reasonable for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member. Medical and surgical services are comparable to those listed for adults except all medically necessary inpatient hospital services, other than psychiatric services, for all persons under the age of 21 will not be limited.

317:30-5-113.Medicare eligible individuals
[Issued 10-3-05]
Payment is made to hospitals for services to Medicare eligible individuals as set forth in this section.
(1) Individuals eligible for Part A and Part B.
(A) Payment is made utilizing the Medicaid allowable for comparable Part B services.
(B) Payment is made for the coinsurance and/or deductible for Part A services for categorically needy individuals.
(2) Individuals who are not eligible for Part A services.
(A) The Part B services are to be filed with Medicare. Any monies received from Medicare and any coinsurance and/or deductible monies received from OHCA must be shown as a third party resource on the appropriate claim form for inpatient per diem. The inpatient per diem should be filed with the fiscal agent along with a copy of the Medicare Payment Report.
(B) For individuals who have exhausted Medicare Part A benefits, claims must be accompanied by a statement from the Medicare Part A intermediary showing the date benefits were exhausted.

[Issued 10-3-05]
Payment is made at the lesser of the facilities usual and customary fee or the OHCA fixed per diem rate.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.