OHCA Policies and Rules

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317:30-5-575.General information
[Issued 06-25-11] 
(a) Clinic services. Clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. The term includes the following services furnished to outpatients:
(1) Services furnished at the clinic by or under the direction of a physician or a dentist.
(2) Services furnished outside the clinic, by clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.
(b) Prior authorization. OHCA requires prior authorization for certain procedures to validate the medical need for the service.
(c) Medical necessity. Medical necessity requirements are listed at OAC 317:30-3-1(f).


317:30-5-576.Eligible providers
[Issued 06-25-11] 
(a) General requirements. To be an eligible clinic provider, a clinic must be under the direction of a physician who is on the premises and who is a SoonerCare enrolled provider. In addition, the supervising physician must meet any other applicable licensure or certification required by State law or meet Medicare certification for participation. All clinic providers must have a current contract with the Oklahoma Health Care Authority (OHCA). The OHCA will review all clinic contracts to ensure compliance with all OHCA requirements, as well as all State and Federal laws. The OHCA has discretion and the final authority to approve or deny any provider contract.
(b) National Provider Identification (NPI). The clinic must have an organizational NPI number and each individual licensed physician and licensed non-physician practitioner must have an individual NPI and meet the provider qualification requirements applicable to the same service when it is furnished in other settings.
(c) Written patient care policies. A clinic under this Part must establish, in writing:
(1) a description of health services provided by the clinic;
(2) policies concerning the medical management of health problems including health conditions which require referral to physicians and provision of emergency health services; and
(3) policies concerning the maintenance and review of health records by the physician or dentist.
317:30-5-577.Coordination of care
[Issued 06-25-11]
The SoonerCare member's Primary Care Provider (PCP) is responsible for coordinating or delivering preventive and primary care services which are medically necessary to all SoonerCare members enrolled with him/her. If a service is rendered in the clinic setting, the clinic must forward information for the patient file regarding the diagnosis, services rendered and need for follow-up to the member's PCP, in order to ensure continuity of care.


317:30-5-578.Limitation on services
[Issued 06-25-11]
Coverage is the same for adults and children unless otherwise indicated. Services are subject to the same limitations elsewhere in OHCA rules unless otherwise specified and to professional services rendered by health professionals acting within the scope of practice under State law.
317:30-5-579.Prescription drugs purchased under the 340B Drug Discount Program provided by Clinics

[Issued 09-01-15]

   For 340B Drug Discount Program guidelines refer to section 317:30-5-87.

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.