OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page


317:30-5-1030.Eligible providers

[Revised 09-12-14]
(a) Case management providers.  Services are provided by case managers certified by the State Department of Education as meeting the requirements for providing case management.  SoonerCare School-Based Targeted Case Management (SBTCM) services must be made available to all eligible members and must be delivered on a statewide basis with procedures that ensure continuity of service without duplication and in compliance with federal and state mandates and regulations related to servicing the targeted population in a uniform and consistent manner.  The case managers must be certified by the single state Medicaid agency as meeting the following:

(1) a minimum of five (5) years experience in meeting the case management and service needs of the target population.

(2) a minimum of five (5) years experience in providing all core elements of case management services, including:

(A) individualized strengths and needs assessment;

(B) needs-based service planning;

(C) service coordination, monitoring and advocacy;

(D) service plan review; and

(E) crisis assistance planning.

(3) a minimum of five (5) years experience in developing and implementing Individualized Education Programs (IEP) and/or Individualized Family Service Plans (IFSP) and in meeting the requirements of the IDEA, in accordance with State and Federal law.  Each IEP and/or IFSP is dependent upon the needs of the individual student as determined by consultation that may include any or all of the professions in (A) through (F) of this paragraph.  Those providing input must meet state or national licensure, registration or certification requirements of the profession in which they practice and include:

(A) special education,

(B) school psychologist,

(C) occupational therapist,

(D) physical therapist,

(E) speech language specialist, or

(F) school counselor and other specialists as identified.

(4) a demonstrated ability to collaborate with public and private services providers.

(5) experience in providing and coordinating education support services, including but not limited to Student Assistance, Special Education, Psychology and Counseling Services.

(6) adequate administrative capacity to fulfill state and federal requirements.

(7) a financial management capacity and system that provides documentation of services and costs.

(8) a capacity to document and maintain individual case records in accordance with state and federal requirements.

(9) a demonstrated ability to meet all state and federal laws governing participation of providers in the SoonerCare program including, but not limited to, the ability to meet federal and state requirements for documentation, billing and audits.

(b) Provider agreement.  A Provider Agreement between the Oklahoma Health Care Authority and the providers for case management services must be in effect before reimbursement can be made for compensable services.

(c) Qualifications of individual case managers.  A targeted case manager for the SBTCM program must:

(1) be employed by the school or their contractor;

(2) possess an appropriate certificate, or meet other comparable requirements as applicable to the profession or discipline in which a person is providing special education, early intervention or related services, in accordance with the requirements of the Oklahoma State Department of Education; or

(3) be licensed, certified or registered as a health care professional in the State, and meet the qualifications for related services staff under the most current provisions of Part B or Part C of the Individuals with Disabilities Education Act.

(d) Provider selection. Provision of case management services must not restrict an individual's free choice of providers. Eligible members must have free choice of the providers of other medical care under the plan.

317:30-5-1031.Coverage by category
[Revised 09-12-14]

(a) Payment is made for case management services to children as set forth in this Section.

(1) Description of case management services. The target group for case management services is individuals 0-21 who are receiving services pursuant to an Individualized Education Program (IEP), an Individualized Family Service Plan (IFSP), a Section 504 Accommodation Plan, or an Individualized Health Service Plan (IHSP), and who have a disability or are medically at risk. A disability is defined as a physical or mental impairment that substantially limits one or more major life activities. Medically at risk refers to individuals who have a diagnosable physical or mental condition that has a high probability of impairing cognitive, emotional, neurological, social or physical development.

(A) Services are provided to assist the target population in gaining access to needed medical, social, educational, and other services.  Major components of the service include:

(i) Individualized needs assessment

(ii) Needs-based service planning;

(iii) Service coordination, monitoring and advocacy;

(iv) Services plan review; and

(v) Crisis assistance planning.

(B) Case record documentation of the service components listed in (1) of this subsection is included as a case management activity.  The client has the right to refuse case management and cannot be restricted from services because of a refusal for Case Management Services.

(C) Case management does not include:

(i) Program activities of the agency itself that do not meet the definition of case management.

(ii) Administrative activities necessary for the operation of the agency providing case management services other than the overhead costs directly attributable to targeted case management.

(iii) Diagnostic, treatment or instructional services, including academic testing.

(iv) Services that are an integral part of another service already reimbursed by SoonerCare.

(v) Activities that are an essential part of SoonerCare administration, such as outreach, intake processing, eligibility determination or claims processing.

(2) Non-duplication of services.  To the extent any eligible members in the identified targeted population are receiving TCM services from another provider agency as a result of being members of other covered targeted groups, the providers assures that case management activities are coordinated to avoid unnecessary duplication of service.  To the extent any of the services required by the member are a SoonerCare covered benefit of a managed care organization of which the client is a member, the provider will assure that timely referrals are made and that coordination of care occurs.

(3) Providers.  Case management services must be provided by the schools or their contractors.

(b) Individuals eligible for Part B of Medicare.  Case Management Services provided to Medicare eligible members are filed directly with the fiscal agent.
[Revised 09-12-14]

(a) Reimbursement for SBTCM services is a unit rate based on the analysis of the average annual costs of providing case management services by participating providers. A unit of service is defined as each completed 10 minute increment that meets the description of case management activity with, or on behalf of the individual, his or her parent(s) or legal guardian.
(b) Payment will be made on the basis of claims submitted for payment. The provider will bill for the unit rate for each documented unit of SoonerCare SBTCM service provided to each SoonerCare eligible individual.

[Revised 09-01-17]

Claims should not be submitted until SoonerCare eligibility of the individual has been determined. However, a claim must be received by OHCA within six (6) months of the date of service. If the eligibility of the individual has not been determined after four (4) months from the date of service, a claim should be submitted in order to assure that the claim is filed and reimbursement can be made should the individual be determined eligible at a later date.

317:30-5-1034.Documentation of records
[Revised 09-12-14]
   All case management services rendered must be reflected by documentation in the records. The case manager documents all units of SoonerCare SBTCM services provided on the service record form.

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.