OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

Part 20      LACTATION CONSULTANTS

317:30-5-230.General Information
[Issued 12-01-07]
The primary focus of this service is member-specific support and education regarding breastfeeding, addressing particular issues, and/or managing lactation crisis.

317:30-5-231.Eligible Providers

[Revised 07-25-08]
Eligible providers must be licensed by the state as a nurse or dietician and be an International Board Certified Lactation Consultants (IBCLCs). Providers must have a current contract on file with the Oklahoma Health Care Authority.


317:30-5-232.Coverage
[Issued 12-01-07]
Lactation Consultant services are covered for pregnant women and women up to 60 days postpartum. SoonerCare members may self-refer or be referred by any provider. Reasons for lactation services include but are not limited to the following:
(1) prenatal education/training for first time mothers;
(2) women who have not previously breastfed, have a history of breastfeeding difficulty, have identified risk factors for breastfeeding difficulty or lactation insufficiency (e.g., history of breast surgery, infertility, hormonal imbalance, diabetes, obesity);
(3) women expecting an infant with risk factors for ineffective breastfeeding (e.g., preterm, multiples, congenital birth defects);
(4) latch-on difficulties;
(5) low milk supply;
(6) breastfeeding a premature baby (36 weeks or less gestation);
(7) breastfeeding multiples; and
(8) a baby with special needs (e.g., Down Syndrome, cleft lip/or palate).

317:30-5-233.Limitations

[Revised 07-25-08]
(a) Services billed by a contracted IBCLC are only covered when performed in the IBCLC's office setting, patient's home, or other confidential outpatient setting. Payment for inpatient services provided by a Lactation Consultant is included in the hospital's per diem rate.
(b) No separate reimbursement will be made to a facility.
(c) Services are not to duplicate any basic breastfeeding education/training a member may have received through another program such as WIC or the Children's First Program and services must be problem focused.
(d) Services provided by a contracted IBCLC must be provided face-to-face and in an individual setting.
(e) Reimbursement is limited to not more than 6 sessions per pregnancy and must be objectively documented as medically necessary.

317:30-5-234.Reimbursement

[Revised 07-25-08]
IBCLCs who are employed by or remunerated by another provider may not bill the SoonerCare program directly for services if that billing would result in duplicate payment for the same service.

317:30-5-235.Documentation
[Issued 12-01-07]
All services must be documented in the member's medical record. All prenatal and postpartum lactation sessions must, at a minimum, include the following:
(1) date of service;
(2) start and stop time for each session;
(3) documentation of services provided;
(4) practitioner's signature; and
(5) recommendation and plan of care.

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.