OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

Part 17      MEDICAL SUPPLIERS

317:30-5-210.Eligible providers
[Revised 08-01-20]

All eligible medical suppliers must have a current contract with the Oklahoma Health Care Authority (OHCA). The supplier must comply with all applicable state and federal laws. Effective January 1, 2011, all suppliers of medical supplies, equipment, and appliances  must be accredited by a Medicare deemed accreditation organization for quality standards for durable medical equipment (DME) suppliers in order to bill the SoonerCare program. For coverage of orthotics and prosthetics, refer to Oklahoma Administrative Code (OAC) 317:30-5-211.13. OHCA may make exceptions to this standard based on the exemptions provided by the Centers for Medicare and Medicaid Services (CMS) for Medicare accreditation, if the provider is a government-owned entity, or at a provider's request and at the discretion of OHCA based on access issues and/or agency needs for SoonerCare members. Additionally, unless an exception is granted from the OHCA, all DME providers must meet the following criteria:

(1) DME providers are required to have a physical location in the State of Oklahoma, or within a designated range of the Oklahoma State border, as determined by the OHCA. The OHCA may make exceptions to this requirement if a DME provider provides a specialty item, product, or service, which is not otherwise available to SoonerCare members within the State of Oklahoma. Provider contracts for out-of-state DME providers will be reviewed on a case-by-case basis for specialty items only. The OHCA has discretion and the final authority to approve or deny any provider contract.

(2) DME providers are required to comply with Medicare DME Supplier Standards for medical supplies, equipment, and appliances provided to SoonerCare members, except the requirement to meet surety bond requirements, as specified in 42 C.F.R. 424.57(c).

(3) Complex rehabilitation technology (CRT) suppliers are considered DME providers. Only CRT suppliers may bill CRT procedure codes. A CRT supplier means a company or entity that:

(A) Is accredited by a recognized accrediting organization as a supplier of CRT;

(B) Is an enrolled Medicare supplier and meets the supplier and quality standards established for DME suppliers, including those for CRT, under the Medicare program;

(C) Employs as a W-2 employee at least one (1) qualified CRT professional, also known as assistive technology professional, for each location to:

(i) Analyze the needs and capacities of complex-needs patients in consultation with qualified health care professionals;

(ii) Participate in selecting appropriate CRT items for such needs and capacities; and

(iii) Provide the complex-needs patient technology related training in the proper use and maintenance of the CRT items.

(D) Requires a qualified CRT professional be physically present for the evaluation and determination of the appropriate CRT;

(E) Has the capability to provide service and repair by qualified technicians for all CRT items it sells; and

(F) Provides written information to the complex-needs patient prior to ordering CRT as to how to access service and repair.

317:30-5-210.1.Coverage for adults

[Revised 08-01-20]
   Coverage of medical supplies, equipment, and appliances for adults complies with 42 Code of Federal Regulations (C.F.R.)
' 440.70 and is specified in Oklahoma Administrative Code (OAC) 317:30-5-211.1 through OAC 317:30-5-211.19.  Orthotics and prosthetics are not a covered service for adults with the exception of breast prosthetics and support accessories (Refer to OAC 317:30-5-211.13).

317:30-5-210.2.Coverage for children
[Revised 08-01-20]

(a) Coverage. Medical supplies, equipment, and appliances are covered for children. In addition, orthotics and prosthetics are covered items for children only, except as specified in OAC 317:30-5-211.3.

(b) EPSDT. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, supplies, or equipment that are determined to be medically necessary for a child, and which are included within the categories of mandatory and optional services in Section 1905(a) of Title XIX, are covered regardless of whether such services, supplies, or equipment are listed as covered in Oklahoma's State Plan.

(c) Medical necessity. Federal regulations require the Oklahoma Health Care Authority (OHCA) to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or that are considered experimental.

317:30-5-211.Coverage for adults
[Revoked 07-01-07]

317:30-5-211.1.Definitions
[Revised 08-01-20]

The following words and terms, when used in this Part, have the following meaning, unless the context clearly indicates otherwise.

"Activities of daily living-basic" means a series of activities performed on a day-to-day basis that are necessary to care for oneself (e.g., personal hygiene, dressing, eating, maintaining continence and transferring).

"Activities of daily living-instrumental "means activities thatare not necessarily required on a daily basis, but are important to being able to live independently (e.g., basic communication skills, transportation, meal preparation, shopping, housework, managing medication and managing personal finances).

"Capped rental" means monthly payments for the use of the medical supplies, equipment, and appliances for a limited period of time not to exceed thirteen (13) months. Items are considered purchased and owned by the Oklahoma Health Care Authority (OHCA) after thirteen (13) months of continuous rental.

"Certificate of medical necessity (CMN)" means a certificate which is required to help document the medical necessity and other coverage criteria for selected items. Those items are defined in this Chapter. The CMN must include the member's diagnosis, the reason the equipment is required, and the physician's, non-physician provider's (NPP's), or dentist's estimate, in months, of the duration of its need.

"Complex rehabilitation technology" means medically necessary durable medical equipment and items that are individually configured to meet specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living of a patient with complex needs. Such equipment and items include, but are not limited to, individually configured power wheelchairs and accessories, individually configured manual wheelchairs and accessories, adaptive seating and positioning systems and accessories, and other specialized equipment such as standing frames and gait trainers.

"Customized equipment and/or appliances" means items of equipment and/or appliances which have been uniquely constructed or substantially modified for a specific member according to the description and orders of the member's treating physician or other qualified medical professional. For instance, a wheelchair would be considered "customized" if it has been:

(A) Measured, fitted, or adapted in consideration of the member's body size, disability, period of need, or intended use;

(B) Assembled by a supplier or ordered from a manufacturer who makes available customized features, modifications, or components for wheelchairs; and

(C) Intended for an individual member's use in accordance with instructions from the member's physician.

"Equipment and/or appliances" means items that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, can be reusable or removable, and are suitable for use in any setting in which normal life activities take place other than a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.  Refer to 42 Code of Federal Regulations (C.F.R.) 440.70(b).

"Face-to-face encounter" means a patient visit in which a practitioner, as defined by 42 C.F.R. 440.70(f), completes a face-to-face assessment related to the primary reason the beneficiary requires durable medical equipment.  The face-to-face encounter must occur no more than six (6) months prior to the start of services.  The ordering physician must document the face-to-face encounter, including the practitioner who conducted the encounter and the date of the encounter. Clinical findings must be incorporated into a written or electronic document included in the beneficiary's medical record. The face-to-face encounter may occur through telehealth.

"Invoice" means a document that provides the following information when applicable: the description of product, quantity, quantity in box, purchase price, NDC, strength, dosage, provider, seller's name and address, purchaser's name and address, and date of purchase. At times, visit notes will be required to determine how much of the supply was expended. When possible, the provider should identify the SoonerCare member receiving the equipment or supply on the invoice.

"Medical supplies" means health care related items that are consumable or disposable, or cannot withstand repeated use by more than one (1) individual, that are required to address an individual medical disability, illness, or injury. Medical supplies do not include skin care creams, cleansers, surgical supplies, or medical or surgical equipment.

"OHCA CMN" means a certificate required to help document the medical necessity and other coverage criteria for selected items. Those items are defined in this Chapter. The CMN must include the member's diagnosis, the reason equipment is required, and the physician's, NPP's, or dentist's estimate, in months, of the duration of its need. This certificate is used when the OHCA requires a CMN and one (1) has not been established by CMS.

"Orthotics" means a device used to support, align, prevent or correct deformities, protect a body function, improve the function of movable body parts or to assist a dysfunctional joint.

"Patient with complex needs"means an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities.

"Prosthetics" means an artificial substitute which replaces all or part of a body organ or replaces all or part of the function of a permanently inoperative, absent, or malfunctioning body part.

"Provider" refers to the treating provider and must be a physician [Medical Doctor (MD), or Doctor of Osteopathy, (DO)], a NPP [Physician Assistant (PA), or Advanced Practice Registered Nurse (APRN)], or a dentist [Doctor of Dental Surgery (DDS), or Doctor of Medicine in Dentistry (DMD)].

317:30-5-211.2.Medical necessity
[Revised 08-01-20]

(a) Coverage.  Coverage is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member, in accordance with state and federal Medicaid law, including, but not limited to, Oklahoma Administrative Code (OAC) 317:30-3-1(f).  The member's diagnosis must warrant the type of equipment or supply being purchased or rented.  Items that are used for the following are not a benefit to a member of any age:

(1) Routine personal hygiene;

(2) Education;

(3) Exercise;

(4) Convenience, safety, or restraint of the member, or his or her family or caregiver;

(5) Participation in sports; and/or

(6) Cosmetic purposes.

(b) Ordering requirements.  All medical supplies, equipment, and appliances as defined by 42 Code of Federal Regulations (C.F.R.) ' 440.70 (b)(3) and OAC 317:30-5-211.1, nursing services, and home health aide services provided by a home health agency, must be ordered by a physician as part of a written plan of care.

(1) The plan of care must be reviewed in accordance with 42 C.F.R. ' 440.70.  Medical supplies, equipment, and appliances must be reviewed annually by the ordering physician.  Nursing services and home health aide services provided by a home health agency must be reviewed every sixty (60) days by the ordering physician.

(2) A face-to-face encounter must occur and be documented, in accordance with 42 C.F.R. ' 440.70 and OAC 317:30-5-211.1.

(c) Prescription requirements.  All prosthetics and orthotics, as those terms are defined by 42 C.F.R. ' 440.120 and OAC 317:30-5-211.1, except for hearing aid batteries and equipment repairs with a cost per item of less than $1,000.00 total parts and labor, require a prescription signed by a physician, a physician assistant, or an advanced practice nurse. Except as otherwise stated in state or federal law, the prescription must be in writing, or given orally and later reduced to writing by the provider filling the order.  Prescriptions are valid for no more than one (1) year from the date written. The prescription must include the following information:

(1) The member's name;

(2) The prescribing practitioner's name;

(3) The date of the prescription;

(4) All items, options, or additional features that are separately billed.  The description can be either a narrative description (e.g. lightweight wheelchair base), a Healthcare Common Procedure Coding System (HCPCS) code, a HCPCS code narrative, or a brand name/model number; and

(5) The prescribing practitioner's signature and signature date.

(d) Certificate of medical necessity (CMN). For certain items or services, the supplier must receive a signed CMN/OHCA CMN from the treating physician, non-physician practitioner, or dentist.  The supplier must have a signed CMN/OHCA CMN in their records before they submit a claim for payment. The CMN/OHCA CMN may be faxed copy, electronic copy, or the original hardcopy.

(e) Place of service.

(1) The Oklahoma Health Care Authority (OHCA) covers medical supplies, equipment, and appliances for use in the member's place of residence and in any setting in which normal life activities take place except for a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any other setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

(2) For members residing in a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any other setting in which payment is or could be made under Medicaid for inpatient services that include room and board, medical supplies, equipment, and appliances are considered part of the facility's per diem rate.

(f) Contracting requirements.  Per 42 C.F.R. 455.410(b), medical supplies, equipment, and appliances may only be ordered or prescribed by a SoonerCare contracted provider.

317:30-5-211.3.Prior authorization (PA)

[Revised 08-01-20]
(a) Coverage.  Coverage is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member, in accordance with state and federal Medicaid law, including, but not limited to, Oklahoma Administrative Code (OAC) 317:30-3-1(f).  The member's diagnosis must warrant the type of equipment or supply being purchased or rented.  Items that are used for the following are not a benefit to a member of any age:

(1) Routine personal hygiene;

(2) Education;

(3) Exercise;

(4) Convenience, safety, or restraint of the member, or his or her family or caregiver;

(5) Participation in sports; and/or

(6) Cosmetic purposes.

(b) Ordering requirements.  All medical supplies, equipment, and appliances as defined by 42 Code of Federal Regulations (C.F.R.) ' 440.70 (b)(3) and OAC 317:30-5-211.1, nursing services, and home health aide services provided by a home health agency, must be ordered by a physician as part of a written plan of care.

(1) The plan of care must be reviewed in accordance with 42 C.F.R. ' 440.70.  Medical supplies, equipment, and appliances must be reviewed annually by the ordering physician.  Nursing services and home health aide services provided by a home health agency must be reviewed every sixty (60) days by the ordering physician.

(2) A face-to-face encounter must occur and be documented, in accordance with 42 C.F.R. ' 440.70 and OAC 317:30-5-211.1.

(c) Prescription requirements.  All prosthetics and orthotics, as those terms are defined by 42 C.F.R. ' 440.120 and OAC 317:30-5-211.1, except for hearing aid batteries and equipment repairs with a cost per item of less than $1,000.00 total parts and labor, require a prescription signed by a physician, a physician assistant, or an advanced practice nurse. Except as otherwise stated in state or federal law, the prescription must be in writing, or given orally and later reduced to writing by the provider filling the order.  Prescriptions are valid for no more than one (1) year from the date written. The prescription must include the following information:

(1) The member's name;

(2) The prescribing practitioner's name;

(3) The date of the prescription;

(4) All items, options, or additional features that are separately billed.  The description can be either a narrative description (e.g. lightweight wheelchair base), a Healthcare Common Procedure Coding System (HCPCS) code, a HCPCS code narrative, or a brand name/model number; and

(5) The prescribing practitioner's signature and signature date.

(d) Certificate of medical necessity (CMN). For certain items or services, the supplier must receive a signed CMN/OHCA CMN from the treating physician, non-physician practitioner, or dentist.  The supplier must have a signed CMN/OHCA CMN in their records before they submit a claim for payment. The CMN/OHCA CMN may be faxed copy, electronic copy, or the original hardcopy.

(e) Place of service.

(1) The Oklahoma Health Care Authority (OHCA) covers medical supplies, equipment, and appliances for use in the member's place of residence and in any setting in which normal life activities take place except for a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any other setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

(2) For members residing in a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any other setting in which payment is or could be made under Medicaid for inpatient services that include room and board, medical supplies, equipment, and appliances are considered part of the facility's per diem rate.

(f) Contracting requirements.  Per 42 C.F.R. 455.410(b), medical supplies, equipment, and appliances may only be ordered or prescribed by a SoonerCare contracted provider.

 

317:30-5-211.4.Rental and/or purchase
[Revised 09-01-15]

(a) Purchase(New or Used). Items may be purchased if they are inexpensive accessories for other DME or the equipment itself will be used for an extended period of time. The OHCA reserves the right to determine whether items of DMEPOS will be rented or purchased.

(b) Rental.

(1) Continuous rental. Items that require regular and ongoing servicing/maintenance are rented for the duration indicated by the physician's order and medical necessity. Examples include, but are not limited to, oxygen and volume ventilators. The rental payment includes routine servicing and all necessary repairs or replacements to make the rented item functional.

(2) Capped rental. Items are rented until the purchase price is reached. Capped rental items may be rented for a maximum of 13 months. If the member changes suppliers during or after the 13th continuous month rental period, this does not result in a new rental period. The supplier that provides the item to the member the 13th month of rental is responsible for supplying the equipment, as well as routine maintenance and servicing after the 13th month. If used equipment is issued to the member, the usual and customary charge reported to the OHCA must accurately reflect that the item is used.

(c) Converting rental to purchase. The majority of DME can be rented as a capped rental for up to a maximum of 13 continuous months. When an item is converted to a purchase during the rental period, the provider must subtract the amount already paid for the rental item from the total purchase price.
317:30-5-211.5.Repairs, maintenance, replacement and delivery
[Revised 08-01-20]

(a) Repairs. Repairs to equipment that either the Oklahoma Health Care Authority or a member owns are covered when they are necessary to make the equipment usable. The repair charge includes the use of "loaner" equipment as required. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, payment cannot be made for the amount in excess. Repairs of rented equipment are not covered.

(b) Maintenance. Routine periodic servicing, such as testing, cleaning, regulating, and checking the member's equipment is considered maintenance and not a separate covered service.  DME suppliers must provide equipment-related services consistent with the manufacturer's specifications and in accordance with all federal, state, and local laws and regulations. Equipment-related services may include, but are not limited to, checking oxygen system purity levels and flow rates, changing and cleaning filters, and assuring the integrity of equipment alarms and back-up systems. However, more extensive maintenance, as recommended by the manufacturer and performed by authorized technicians, is considered repairs. This may include breaking down sealed components and performing tests that require specialized testing equipment not available to the member. The supplier of a capped rental item that supplied the item the thirteenth (13th) month must provide maintenance and service for the item. In very rare circumstances of malicious damage, culpable neglect, or wrongful disposition, the supplier may document the circumstances and be relieved of the obligation to provide maintenance and service.

(c) Replacement.

(1) If equipment that has met the capped rental period and has been in continued use by the member for the equipment's useful life or if the item is irreparably damaged, lost, or stolen, a prior authorization must be submitted to obtain new equipment. The reasonable useful lifetime for capped rental equipment cannot be less than five (5) years. Useful life is determined by the delivery of the equipment to the member, not the age of the equipment.

(2) Replacement parts must be billed with the appropriate Healthcare Common Procedure Coding System (HCPCS) code that represents the item or part being replaced along with a pricing modifier and replacement modifier. If a part that has not been assigned a HCPCS code is being replaced, the provider should use a miscellaneous HCPCS code to bill each part. Each claim that contains miscellaneous codes for replacement parts must include a narrative description of the item, the brand name, model name/number of the item, and an invoice.

(d) Delivery. Medical supplies, equipment, and appliance products are set with usual maximum quantities and frequency limits. Suppliers are not expected to provide these amounts routinely, nor are members required to accept medical supplies, equipment, and appliance products at frequencies or in quantities that exceed the amount the member would typically use. Suppliers must not dispense a quantity of any medical supplies, equipment, and appliance product exceeding a member's expected utilization. The reordering or refilling of medical supplies, equipment, and appliance products should always be based on actual member usage.  Suppliers should stay attuned to atypical utilization patterns on behalf of their members and verify with the ordering physician that the atypical utilization is warranted. Suppliers must exercise the following guidelines in regard to the delivery of medical supplies, equipment, and appliance products:

(1) For medical supplies, equipment, and appliance products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill. This shall be done to ensure that the refilled item is necessary and to confirm any changes/modifications to the order. Contact with the member regarding refills should take place no sooner than seven (7) days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier must deliver the medical supplies, equipment, and appliance product no sooner than five (5) days prior to the end of the usage for the current product. This is regardless of which delivery method is utilized. A member must specifically request the refill before a supplier dispenses the product. Suppliers must not automatically dispense a quantity of supplies on a predetermined basis, even if the member has authorized this in advance. The supplier must have member contact documentation on file to substantiate that the medical supplies, equipment, and appliance product was refilled in accordance with this section.

(2) For medical supplies, equipment, and appliance products that are supplied via mail order, suppliers must bill using the appropriate modifier which indicates that the medical supplies, equipment, and appliance product was delivered via the mail. Reimbursement for medical supplies, equipment, and appliance products supplied and delivered via mail may be at a reduced rate.

(3) For medical supplies, equipment, and appliance products that are covered in the scope of the SoonerCare program, the cost of delivery is always included in the rate for the covered item(s).

317:30-5-211.6.General documentation requirements

[Revised 08-01-20]
(a) Section 1833(e) of the Social Security Act precludes payment to any provider of service unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" [42 United States Code (U.S.C. Section 1395l(e)]. The member's medical records will reflect the need for the care provided. The member's medical records should include the physician's office records, hospital records, nursing home records, home health agency records, records from other health care professionals and test reports. This documentation must be provided for prior authorization requests and available to the Oklahoma Health Care Authority or its designated agent upon request.

(b) Payment is made for durable medical equipment as set forth in this section when a face-to-face encounter has occurred in accordance with provisions of 42 Code of Federal Regulations (C.F.R.) ' 440.70 and Oklahoma Administrative Code 317:30-5-211.1.



317:30-5-211.7.Free choice
[Revised 09-01-15]
   A member has the choice of which provider will fill the prescription or order for a DMEPOS. All providers must inform the member they have a choice of provider when filling or ordering DMEPOS.
317:30-5-211.8.Coverage [REVOKED]

[Revoked 12-03-09]
 

317:30-5-211.9.Adaptive equipment [REVOKED]

[Revoked 08-01-20]

317:30-5-211.10.Medical supplies, equipment, and appliances

[Revised 08-01-20]
(a) Medical supplies, equipment, and appliances.  See the definition for medical supplies, equipment, and appliances at Oklahoma Administrative Code 317:30-5-211.1.

(b) Certificate of medical necessity (CMN). Certain items of medical supplies, equipment, and appliances require a CMN/OHCA CMN which should be submitted with the request for prior authorization. These items include, but are not limited to:

(1) External infusion pumps;

(2) Hospital beds;

(3) Oxygen and oxygen related products;

(4) Pneumatic compression devices;

(5) Support surfaces;

(6) Enteral and parenteral nutrition; and

(7) Osteogenesis stimulator.

(c) Rental. Several medical supplies, equipment, and appliance products are classified as either a capped rental or a continuous rental. Payment for a capped rental is capped at thirteen (13) months and a continuous rental is paid monthly for as long as it is medically necessary. Both require documentation showing that the product is medically necessary.

(d) Purchase.  Medical supplies, equipment, and appliances may be purchased when a member requires the product for an extended period of time.  During the prior authorization review, the Oklahoma Health Care Authority (OHCA) may change the authorization from a rental to a purchase or a purchase to a rental based on the documentation submitted.

(e) Backup equipment. Backup equipment is considered part of the rental cost and is not a covered service without prior authorization.

(f) Home modification. Home modifications that require permanent installation are not covered services as they are not removable and therefore do not meet the definition of medical supplies, equipment, and appliances per 42 Code of Federal Regulations (C.F.R.) ' 440.70.Refer to Title 317, Chapters 40 and 50 for home modifications covered under Home and Community Based Services Waivers including the ADvantage Waiver.

317:30-5-211.11.Oxygen and oxygen equipment

[Revised 09-01-15]

(a) Medical necessity.  Oxygen and oxygen supplies are covered when medically necessary.  Medical necessity is determined from results of arterial blood gas analysis (ABG) or pulse oximetry (SaO2) tests. ABG data are not required for children, but may be used if otherwise available. The test results to document Medical Necessity must be within 30 days of the date of the qualified medical practitioner's Certificate of Medical Necessity. Prior authorization is required after the initial three months of billing whether qualifying tests were done at rest, during sleep, or during exercise. Appropriate documentation of ABG or SaO2 data from the member's chart should be attached to the prior authorization request(PAR).

(1) The ABG or oximetrytest used to determine medical necessity must be performed by a medical professional qualified to conduct such testing.  The test may not be performed or paid for by a DMEPOS supplier,or a related corporation. A referring qualified medical practitioner may perform the test in his/her office as part of routine member care.

(2) In addition to ABG data, the following three tests are acceptable for determining medical necessity for oxygen prescription:

(A) At rest and awake "spot oximetry."

(B) During sleep:

(i) Overnight Sleep Oximetry done inpatient or at home.

(ii) Polysomnogram, which may be used only if medically necessary for concurrent evaluation of another condition while in a chronic stable state.

(C) During exercise with all three of the following  performed in the same testing session.

(i) At rest, off oxygen showing a non-qualifying  result.

(ii) During exercise, off oxygen showing a qualifying event.

(iii) During exercise, on oxygen showing improvement over test (C) ii above.

(3) Certification criteria:

(A) All qualifying testing must meet the following criteria:
(B)  Adults .   Initial requests for oxygen must include ABG or resting oximetry results. At rest and on room air, the arterial blood saturation (SaO2) cannot exceed 89% or the pO2 cannot exceed 59mm Hg.

(C) Children .   Members 20 years of age or less must meet the following requirements:

(i) birth through three years, SaO2 equal to or less than 94%;or(ii) ages four and above, SaO2 level equal to or less than 90%.(iii)Requests from the qualified medical practitioner for oxygen for children who do not meet these requirements should include documentation of themedical necessity based on the child's clinical condition.  These requests are considered on a case-by-case basis.

(b) Certificate of medical necessity.

(1) The DMEPOS supplier must have a fully completed current CMN(CMS-484 or HCA-32 must be used for members 20 years of age and younger) on file to support the claims for oxygen or oxygen supplies, and to establish whether coverage criteria are met and to ensure that the oxygen services provided are consistent with the physician's prescription (refer to instructions from Palmetto Government Benefits Administration, the Oklahoma Medicare Carrier, for further requirements for completion of the CMN).

(2) The CMN must be signed by the qualified medical practitioner prior to submitting the initial claim.  If a verbal order containing qualifying data is received by the DME provider, oxygen and supplies may be dispensed using the verbal order date as the billing date.  The CMN initial date, the verbal order date, and the date of delivery should be the same date. It is acceptable to have a cover letter containing the same information as the CMN, stating the qualified medical practitioner's orders.  The CMN signed by the qualified medical practitioner must be attached to the PAR.

(3) The medical and prescription information on the CMN may be completed by a non-physician clinician, or an employee, for the qualified medical practitioner's review and signature.

(4) When a Certificate ofMedical Necessity for oxygen is recertified, a prior authorization requestwill berequired.

(5) Re-certification andrelatedretestingwill be required every 12 months.

(6)CMN for oxygen services must be updated at least annually and at any time a change in prescription occurs during the year.  All DMEPOS suppliers are responsible for maintaining the prescription(s) for oxygen services and CMN in each member's file. 
(7) The OHCA or its designated agent will conduct ongoing   monitoring of prescriptions for oxygen services to ensure guidelines are followed. Payment adjustments will be made on claims not meeting these requirements.

317:30-5-211.12.Oxygen rental

[Revised 08-01-20]
   A monthly rental payment is made for rental of liquid oxygen systems, gaseous oxygen systems and oxygen concentrators. The rental payment for a stationary system includes all contents and supplies, such as, regulators, tubing, masks, etc., that are medically necessary.  An additional monthly payment may be made for a portable liquid or gaseous oxygen system based on medical necessity.

(1) Stationary oxygen systems and portable oxygen systems are covered items for members residing in their home and in any setting in which normal life activities take place except for a hospital, long-term care facility, intermediate care facility for individuals with intellectual disabilities, or any other setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

(2) For members who meet medical necessity criteria, SoonerCare covers portable liquid or gaseous oxygen systems. Payment for both oxygen contents used with stationary oxygen equipment and oxygen contents used with portable oxygen equipment is included in the monthly payments for oxygen and oxygen equipment. The need for a portable oxygen system must be stated on the CMN. A portable system that is used as a backup system only is not a covered item.

(3) When four (4) or more liters of oxygen are medically necessary, an additional payment will be paid up to one hundred and fifty percent (150%) of the allowable for a stationary system when billed with the appropriate modifier.

 

 

317:30-5-211.13.Orthotics and prosthetics

[Revised 08-01-20]
(a) Orthotics and prosthetics are classified as an optional benefit by the Center for Medicare and Medicaid Services (CMS) and are administered as per 42 C.F.R.
' 440.120. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.1 for definitions of orthotics and prosthetics.

(b) There is no coverage of orthotics for adults.

(c) Coverage of prosthetics for adults is limited to one (1) breast prosthesis and support accessories and two (2) prosthetic devices insurted during surgery.

(1) Breast prosthesis and support accessories.

(A) Payment is limited to:

(i) One (1) prosthetic garment with mastectomy form every twelve (12) months for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;

(ii) Two (2) mastectomy bras per year; and

(iii) One (1) silicone or equal breast prosthetic per side every twenty-four (24) months; or

(iv) One (1) foam prosthetic per side every six (6) months.

(B) Payment will not be made for both a silicone and a foam prosthetic in the same twelve (12) month period.

(C) Breast prostheses, bras, and prosthetic garments must be purchased from a Board Certified Mastectomy Fitter.

(D) A breast prosthesis can be replaced if:

(i) Lost;

(ii) Irreparably damaged (other than ordinary wear and tear); or

(iii) The member's medical condition necessitates a different type of item and the physician provides a new prescription explaining the need for a different type of prosthesis.

(E) External breast prostheses are not covered after breast reconstruction is performed except in instances where a woman with breast cancer receives reconstructive surgery following a mastectomy, but the breast implant fails or ruptures and circumstances are such that an implant replacement is not recommended by the surgeon and/or desired by the member.

(2) Prosthetic devices inserted during surgery.  Separate payment is made for prosthetic devices inserted during the course of surgery when the prosthetic devices are not integral to the procedure and are not included in the reimbursement for the procedure itself.

317:30-5-211.14.Nutritional support

[Revised 08-01-20]
(a) Enteral nutrition.  Enteral nutrition administered only via gravity, syringe, or pump is covered for children and adults at home. Refer to pharmacy policy related to coverage of food supplements at Oklahoma Administrative Code (OAC) 317:30-5-72.1. For enteral nutrition authorization guidelines, see OAC 317:30-5-211.20.

(b) Parenteral nutrition.  The member must require intravenous feedings to maintain weight and strength commensurate with the member's overall health status.  Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.

(1) The member must have a permanent impairment.  Permanence does not require a determination that there is no possibility that the member's condition may improve sometime in the future.  If the judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least three (3) months), the test of permanence is met.  Parenteral nutrition will be denied as a non-covered service in situations involving temporary impairments.

(2) The member must have a condition involving the small intestine, exocrine glands, or other conditions that significantly impair the absorption of nutrients.  Coverage is also provided for a disease of the stomach and/or intestine that is a motility disorder and impairs the ability of nutrients to be transported through the GI system, and other conditions as deemed medically necessary.  There must be objective medical evidence supporting the clinical diagnosis.

(3) Re-certification of parenteral nutrition will be required as medically necessary and determined by the Oklahoma Health Care Authority (OHCA) medical staff.

(c) Long-term care facility enteral and parenteral nutrition. Enteral and parenteral nutrition products supplied to long-term care facility residents will be included in the long-term care facility per diem rate.

(d) Claim submission requirements.  A written signed and dated order must be received by the supplier before a claim is submitted to the OHCA.  If the supplier bills an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.  The ordering physician is expected to see the member within thirty (30) days prior to the initial certification or required re-certification.  If the physician does not see the member within this time frame, the physician must document the reason why and describe what other monitoring methods were used to evaluate the member's parenteral nutrition needs.

 

317:30-5-211.15.Medical Supplies
[Revised 08-01-20]

The Oklahoma Health Care Authority (OHCA) provides coverage for medically necessary supplies that are prescribed by the appropriate medical provider and meet the member's specific needs. Medical supplies include, but are not limited to, IV therapy supplies, diabetic supplies, catheters, colostomy and urostomy supplies, and incontinence supplies.

317:30-5-211.16.Coverage for long-term care facility residents
[Revised 08-01-20]

For residents in a long-term care facility, medical supplies, equipment and appliances are included in the facility's per diem rate. Prosthetics and orthotics are paid separately from the per diem rate. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.13 for coverage.



317:30-5-211.17.Wheelchairs
[Revised 08-01-20]

(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.

(1) "Assistive technology professional" or "ATP" means a for-service provider who is involved in analysis of the needs and training of a consumer in the use of a particular assistive technology device or is involved in the sale and service of rehabilitation equipment or commercially available assistive technology products and devices. All ATPs are required to be credentialed by Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

(2) "Custom seating system" means a wheelchair seating system which is individually made for a member using a plaster model of the member, a computer generated model of the member (e.g., CAD-CAM technology), or the detailed measurements of the member to create either:

(A) a molded, contoured, or carved (foam or other suitable material) custom-fabricated seating system that is incorporated into the wheelchair base; or

(B) a custom seating system made from multiple pre-fabricated components or a combination of custom fabricated materials and pre-fabricated components which have been configured and attached to the wheelchair base or incorporated into a wheelchair seat and/or back in a manner that the wheelchair could not be easily re-adapted for use by another individual.

(3) "Specialty evaluation" means the determination and documentation of the consumer's pathology, history and prognosis, and the physiological, functional, and environmental factors that impact the selection of an appropriate wheeled mobility system.

(b) Medical Necessity. Medical necessity, pursuant to Oklahoma Administrative Code (OAC) 317:30-5-211.2, is required for a wheelchair to be covered and reimbursed by SoonerCare. Only one (1) wheelchair is covered as medically necessary during its reasonable useful lifetime, unless the member's documented medical condition indicates the current wheelchair no longer meets the member's medical need. Backup wheelchairs are not covered items.

(c) Prior authorization. Prior authorization, pursuant to OAC 317:30-5-211.3, is required for selected wheelchairs to be covered and reimbursed by SoonerCare. All prior authorization requests for the purchase of a wheelchair must indicate the length of the warranty period and what is covered under the warranty.

(1) Wheelchairs, wheelchair parts and accessories, and wheelchair modifications that are beneficial primarily in allowing the member to perform leisure or recreational activities are not considered medically necessary and will not be authorized.

(2) Wheelchair parts, accessories, and/or modifications that are distinctly and separately requested and priced from the original wheelchair request may require prior authorization.

(3) The Oklahoma Health Care Authority will deny prior authorization requests when the required forms have not been fully completed or the member's medical record does not provide sufficient information to establish medical necessity or to determine that the criteria for coverage has been met.

(d) Coverage and limitations. For members who reside in a long-term careg facility or intermediate care facility for individuals with intellectual disabilities, all standard manual and power wheelchairs are considered part of the facility's per diem rate. Repairs and maintenance for wheelchairs are considered part of the facility's per diem rate.

(e) Rental, repairs, maintenance, and delivery.  Refer to OAC 317:30-5-211.4 through 317:30-5-211.5.

(f) Documentation.

(1) The specialty evaluation or wheelchair selection documentation must be submitted with the prior authorization request.

(2) The specialty evaluation or wheelchair selection must be performed no longer than ninety (90) days prior to the submission of the prior authorization request.

(3) The results of the specialty evaluation or wheelchair selection documentation must be supported by the information submitted on the member's medical record.

(4) A copy of the dated and signed written specialty evaluation or wheelchair selection document must be maintained by the wheelchair provider. The results of the specialty evaluation or wheelchair selection must be written, signed, and dated by the medical professional who evaluated the member or the ATP who was involved in the wheelchair selection for the member.

 

 
317:30-5-211.18.Ownership of durable medical equipment
[Issued 12-03-09]
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) purchased by SoonerCare are the property of the Oklahoma Health Care Authority (OHCA) to be used for the benefit of the requesting member until it is no longer medically necessary. At such time as the item is no longer medically necessary, OHCA or an OHCA contractor may retrieve the DMEPOS product if it is determined to be administratively and fiscally prudent.

 

317:30-5-211.19.Quality assurances and safeguards
[Issued 06-25-11]
All SoonerCare billed durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) must have the following quality assurances and safeguards:
(1) All DMEPOS items provided to SoonerCare members must meet manufacturer standards. The equipment must be provided by trained professionals in a manner that is both nationally recognized for safe and effective member care and that meets the member's needs and therapeutic goals, and that the member has received the appropriate education in order to minimize any hazard or safety risks.
(A) DMEPOS suppliers must only provide items that meet applicable state and federal regulations and medical device effectiveness and safety standards.
(B) DMEPOS suppliers must make available the manufacturer copies of the features, warranties, and instructions for each type of item.
(2) All DMEPOS supplier personnel who are educating SoonerCare members, or repairing SoonerCare DMEPOS items, must be working within the scope of their practice and meet all state and federal requirements.
(A) DMEPOS suppliers must have equipment delivery, set-up, and member education accomplished by competent technical and professional personnel who are licensed, certified, or registered, and who are functioning within their scope of practice as required by state and federal standards.
(B) DMEPOS suppliers must provide the appropriate information about equipment set-up features, routine use, troubleshooting, cleaning, and maintenance.
(C) DMEPOS suppliers must provide education and instructional material that is tailored to the member's needs, abilities, learning preferences, and language.
(D) DMEPOS suppliers must make repairs and maintenance available on all equipment and item(s) provided.
(3) DMEPOS suppliers must implement a program that promotes the safe use of equipment, and minimizes safety risks, infections, and hazards. Suppliers must investigate any incident, injury, or infection in which DMEPOS items were a contributor.
(A) DMEPOS suppliers must provide relevant information about infection control issues related to the use of the equipment and item(s) provided.
(B) DMEPOS suppliers must ensure that the member can use all equipment and item(s) provided safely and effectively in the settings of anticipated use.
(4) DMEPOS suppliers must make available their regular business hours and after-hour access telephone numbers for customer service, and for information about equipment repair, and emergency coverage.
(5) DMEPOS suppliers must provide follow-up services to members, consistent with the types of equipment and item(s) provided, and recommendations from the prescribing physician.
317:30-5-211.20.Enteral nutrition

[Issued 08-01-20]
(a) Enteral Nutrition. Enteral nutritionis the delivery of nutrients directly into the stomach, duodenum or jejunum.

(b) Medical necessity. Enteral nutrition supplies must be determined by a physician to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. Requests by medical providers for enteral nutrition supplies in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Documentation must include:

(1) Diagnosis;

(2) Certificate of Medical Necessity (CMN);

(3) Ratio data;

(4) Route;

(5) Caloric intake; and

(6) Prescription.

(7) For full guidelines, please refer to www.okhca.org/mau.

(d) Reimbursement.

(1) Extension sets and Farrell bags are not covered when requested separately from the supply kits;

(2) Enteral nutrition for individuals in long-term care facilities is not separately reimbursed as this is included in the per diem rate.

(e) Non-covered items. The following are non-covered items:

(1) Orally administered enteral products and/or related supplies;

(2) Formulas that do not require a prescription unless administered by tube;

(3) Food thickeners, human breast milk, and infant formula;

(4) Pudding and food bars; and

(5) Nursing services to administer or monitor the feedings of enteral nutrition.

317:30-5-211.21.Incontinence supplies

[Issued 08-01-20]
(a) Incontinence supplies and services. Incontinence supplies and services are those supplies that are used to alleviate or prevent skin breakdown or excoriation associated with incontinence.

(b) Medical necessity. Incontinence supplies must be determined by a physician to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for incontinence supplies in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Documentation must include:

(1) A signed provider prescription specifying the requested item;

(2) A documented diagnosis of an underlying chronic medical condition that involves loss of bladder or bowel control;

(3) Documentation must include the height and weight of the member, the type of incontinence (bowel/bladder/combined), and expected length of need;

(4) Requests submitted for underwear/pull-on(s) the member must be ambulatory or in toilet training;

(5) The member may qualify for incontinence supplies for a short period of time when the member has documented full-skin thickness injuries;

(6) When requesting wipes as incontinence supplies, documentation must be submitted specific to the supply being requested. Disposable wipes are only allowed when diapers have been approved;

(7) For full guidelines, please refer to www.okhca.org/mau.

(d) Quantity limits. There is a quantity limit to the products allowed as well as product combinations. For a listing of quantity limits on specific products, refer to the OHCA website, under the Durable Medical Equipment page, "Incontinence Supplies". Requests for quantities or combinations outside of the limits published will require additional medical review for approval.

(e) Non-covered items. The following are non-covered items:

(1) Incontinence supplies for members under the age of four (4) years;

(2) Reusable underwear and/or reusable pull-ons;

(3) Reusable briefs and/or reusable diapers;

(4) Diaper service for reusable diapers;

(5) Feminine hygiene products;

(6) Disposable penile wraps; and

(7) Shipping costs.

317:30-5-211.22.Pulse oximeter

[Issued 08-01-20]
(a) Pulse oximeter. Pulse oximeter is a device used for measuring blood oxygen levels in a non-invasive manner.

(b) Medical necessity. Pulse oximeters must be determined by a physician to be medically necessary and documented in the member = s plan of care as medically necessary and used for medical purposes. A request by a medical provider for pulse oximeters in and of itself shall not constitute medical necessity.  The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity.  Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and OAC 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Documentation must include:

(1)A current oxygen order signed and dated by an OHCA-contracted physician, along with a certificate of medical necessity (CMN);

(2) Pertinent information relating to the member's underlying diagnosis and condition which results in the need for the oximeter and supplies, including documentation of unstable airway events and documentation of current monitor readings if available; and

(3) Documentation of an available trained caregiver in the home who is able to intervene and address changes in the member's oxygen saturation levels in a medically safe and appropriate manner.

(4) For full guidelines, please refer to www.okhca.org/mau.

(d) Reimbursement.

(1) Temporary probe covers are not reimbursed separately for rented oximeters as they are included in the price of the rental.

(2) Pulse oximeters are not reimbursed in conjunction with apnea monitors.

317:30-5-211.24.Parenteral nutrition

[Issued 08-01-20]
(a) Parenteral nutrition (PN). PN isthe provision of giving nutritional requirements intravenously.

(b) Medical necessity. PN must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for PN in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2).

(1)Hospital records that have objective medical evidence supporting the clinical diagnosis; if applicable;

(2) A certificate of medical necessity;

(3) A prescription; and

(4) Caloric Intake.

(5) For full guidelines, please refer to www.okhca.org/mau.

(d) Reimbursement.

(1) Supply kits are all inclusive, unbundled supplies (e.g. gloves, tubing, etc.) are not reimbursable for PN.

(2) Pumps are rented as a capped rental.

 

 

317:30-5-211.25.Continuous glucose monitoring

[Issued 08-01-20]
(a) Continuous glucose monitoring (CGM). CGM means a minimally invasive system that measures glucose levels in subcutaneous or interstitial fluid. CGM provides blood glucose levels and can help members make more informed management decisions throughout the day.

(b) Medical necessity. CGM must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for CGM in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity. CGM devices must be approved by the U.S. Food and Drug Administration (FDA) as non-adjunctive and must be used for therapeutic purposes. Devices may only be used for members within the age range for which the devices have been FDA approved.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Requests for CGM must include all of the following documentation:

(1) Prescription by a physician, physician assistant, or an advanced practice registered nurse;

(2)Member diagnosis that correlates to the use of CGM;

(3) Documentation of the member testing to include the frequency each day;

(4) Documentation member is insulin-treated to include frequency of daily or is using insulin pump therapy;

(5) Documentation member's insulin treatment regimen requires frequent adjustment;

(6) The member and/or family member has participated in age appropriate diabetes education, training, and support prior to beginning CGM; and

(7) In-person or telehealth visit [within the last six (6) months] between the treating provider, member and/or family to evaluate their diabetes control.

(8) For full guidelines please refer to www.okhca.org/mau.

317:30-5-211.26.Bathroom equipment

[Issued 08-01-20]
(a) Bathroom equipment. Bathroom equipment is used for bathing and toileting and may be considered primarily medical in nature if used in the presence of an illness and/or injury and if it is necessary for activities of daily living that are considered to be essential to health and personal hygiene.

(b) Medical necessity. Bathroom equipment must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for bathroom equipment in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2).

(1) Current written prescription for specific medical supply, equipment, and appliance item;

(2) Letter of Medical Necessity;

(3) Product Information;

(4) Manufacturer's Suggested Retail Price (MSRP) for each item requested

(5) For full guidelines, please refer to www.okhca.org/mau.

317:30-5-211.27.Positive airway pressure (PAP) devices

[Issued 08-01-20]
(a) PAP devices. PAP devices are both a single level continuous positive airway pressure device (CPAP), and/or a bi-level respiratory assist device with or without back-up rate when it is used in the treatment of obstructive sleep apnea.

(b) Medical Necessity. PAP devices must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for PAP devices in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2).

(1) A face-to-face clinical evaluation by the treating qualified medical professional within six (6) months prior to receiving device;

(2) Qualifying polysomnogram, performed in a sleep diagnostic testing facility, that is dated within one (1) year of the prior authorization request submission;

(3) The patient and/or his or her caretaker have received instruction from the supplier of the device in the proper use and care of the equipment; and

(4) Medical records supporting the need for a PAP device.

(5) For full guidelines, please refer to www.okhca.org/mau.

317:30-5-211.28.Sleep studies

[Issued 08-01-20]
(a) Sleep studies. Sleep studies are the continuous and simultaneous monitoring and recording of specified physiological and pathophysiological parameters during a period of sleep for six (6) or more hours. The study is used to diagnose a variety of sleep disorders and to evaluate a patient's response to therapies such as continuous positive airway pressure (CPAP). A sleep study requires physician review, interpretation, and report.

(b) Medical necessity. Sleep studies must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. A request by a medical provider for sleep studies in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Documentation requirements include:

(1) Legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient;

(2) All pages in the prior authorization request must be clear and legible;

(3) Face-to-face evaluation by the ordering practitioner, the supervising physician, or the interpreting physician; and

(4) Medical records to support the medical indication for the sleep study including results of sleep scale.

(5) For full guidelines, please refer to www.okhca.org/mau.

(d) Reimbursement.

(1) Only sleep studies performed in a sleep diagnostic testing facility may be reimbursable.

(2) A split study beginning on a given date with the titration beginning after midnight on the subsequent date is one (1) study and may not be billed as two (2) consecutive studies.

317:30-5-212.Coverage for children [REVOKED]
[Revoked 12-03-09]
317:30-5-213.Coverage for vocational rehabilitation [REVOKED]
[Revoked 8-05-98]

317:30-5-214.Coverage for individuals eligible for Part B of Medicare
[Revised 7-1-02]
Payment is made to medical suppliers utilizing the Medicaid allowable for comparable services.

317:30-5-215.Billing requirements
[Revoked 07-01-07]

317:30-5-216.Prior authorization requests [REVOKED]

[Revoked 08-01-20]

317:30-5-217.Billing

[Revised 09-01-15]

(a) Procedure codes. It is the supplier's responsibility to ensure that claims for the supply or equipment are submitted with the most appropriate HCPCS code as assigned by the Medicare PDAC or its successor. When the most appropriate procedure code is not used, the claim will be denied. When a specific procedure code has not been assigned to an item, an invoice is required which must contain a full description of the equipment or supply.

(b) Rental. Claims for rental should indicate the first date of service and the inclusive dates of rental as part of the description of services. The appropriate modifier must be included. Only one month's rental should be entered on each detail line.

(c) Invoice. For manually priced items, after the service has been provided, the supplier is required to include a copy of the invoice documenting the supplier's cost of the item with the claim.

(d) Place of service. The appropriate indicator for the patient's place of residence must be entered.

(e) Prescribing provider. The name of the prescribing provider must be included for claims processing and entered in the appropriate block.
(f) Proof of Delivery. Items must be received by the member before billing OHCA. Proof of delivery must be retained by the provider in the member's file and provided to the OHCA upon request. In addition, for manually priced items, evidence of proof of delivery must be attached to the claim for adjudication.

317:30-5-218.Reimbursement

[Revised 08-01-20]
(a) Medical supplies, equipment and appliances.

(1) Reimbursement for medical supplies, equipment, and appliances will be made using an amount derived from the lesser of the Oklahoma Health Care Authority (OHCA) maximum allowable fee or the provider's usual and customary charge. The maximum allowable fee is the maximum amount that the OHCA will pay a provider for an allowable procedure. When a code is not assigned a maximum allowable fee for a unit of service, a fee will be established.

(2) The fee schedule will be reviewed annually.  Adjustments to the fee schedule may be possible at any time based on efficiency, budget considerations, federal regulations, and quality of care as determined by the OHCA.

(3) Payment for medical supplies, equipment, and appliances will be calculated using the rate methodologies found in the Oklahoma Medicaid state plan.

(4) Payment is not made for medical supplies, equipment, and appliances that are not deemed as medically necessary or considered over the counter.

(5) OHCA does not pay medical supplies, equipment, and appliances providers separately for services that are included as part of the payment for another treatment program.  For example, all items required during inpatient stays are paid through the inpatient payment structure.

(6) Medical supplies, equipment, and appliance products purchased at a pharmacy are paid the equivalent to Medicare Part B, Average Sales Price (ASP) + six percent (6%).  When ASP is not available, an equivalent price is calculated using Wholesale Acquisition Cost (WAC).  If no Medicare, ASP, or WAC pricing is available, then the price will be calculated based on invoice cost.

(b) Manually-priced medical equipment and supplies. There may be instances when manual pricing is required.  When it is, the following pricing methods will be used:

(1) Invoice pricing. Reimbursement is at the provider's documented Manufacturer's Suggested Retail Price (MSRP) minus thirty percent (30%) or at the provider's invoice cost plus thirty percent (30%), whichever is the lesser of the two.

(2) Fair market pricing. OHCA may establish a fair market price through claims review and analysis.  For a list of medical equipment and supplies that are fair market-priced, refer to the OHCA website at www.okhca.org for the Fair Market Value List (Selected medical supplies, equipment, and appliance items priced at Fair Market Price).

(c) Oxygen equipment and supplies.

(1) Payment for stationary oxygen systems (liquid oxygen systems, gaseous oxygen systems, and oxygen concentrators) is based on continuous rental, i.e., a continuous monthly payment that is made as long as it is medically necessary. The rental payment includes all contents and supplies, e.g. regulators, tubing, masks, etc. Portable oxygen systems are considered continuous rental. Ownership of the equipment remains with the supplier.

(2) Separate payment will not be made for maintenance, servicing, delivery, or for the supplier to pick up the equipment when it is no longer medically necessary.  In addition, the provider/supplier will not be reimbursed for mileage.

(3) Payment for oxygen and oxygen equipment and supplies will not exceed the Medicare fee for the same procedure code.

(4) For residents in a long-term care facility, durable medical equipment products, including oxygen, are included in the facility's 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.