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317:30-5-40.1.General information

[Revised 11-26-18]
(a) This Chapter applies to coverage in an inpatient and/or outpatient setting. Coverage is the same for adults and children unless otherwise indicated.

(b)  Professional Services.  Payment is made to a participating hospital group or corporation for hospital based physician's services. The hospital must have a Hospital Group Physician's Contract with OHCA for this method of billing.

(c) Prior Authorization.  OHCA requires prior authorization for certain procedures to validate the medical need for the service.

(d) Medical necessity.  Medical necessity requirements are listed at OAC 317:30-3-1(f) and 317:30-5-20.



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.