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Part 35      RURAL HEALTH CLINICS

317:30-5-355.Eligible providers
[Revised 11-14-95]
Rural Health Clinics (RHCs) certified for participation in the Medicare Program are considered eligible for participation in the Medicaid Program. RHCs may be provider-based (i.e., clinics that are an integral part of a hospital, skilled nursing facility, or home health agency that participates in Medicare) or independent (freestanding), and may include Indian Health Clinics. To participate, a RHC must have a current contract on file with the Oklahoma Health Care Authority (OHCA).

317:30-5-355.1.Definition of services

[Revised 01-06-2020]

The Rural Health Clinic (RHC) benefit package, as described in Title 42 of the Code of Federal Regulations (CFR),' 440.20, consists of two (2) components: RHC services and other ambulatory services.

(1) RHC services. RHC services are covered when furnished to a member at the clinic or other location, including the member's place of residence. These services are described in this Section.

(A) Core services.  As set out in 42 CFR ' 440.20(b), RHC "core" services include, but are not limited to:

(i) Physician's services;

(ii) Services and supplies incident to a physician's services;

(iii) Services of advanced practice registered nurses (APRNs), physician assistants (PAs), certified nurse midwives (CNMs), or specialized advanced practice nurse practitioners;

(iv) Services and supplies incident to the services of APRNs and PAs (including services furnished by CNMs);

(v) Visiting nurse services to the homebound;

(vi) Clinical psychologist (CP) and clinical social worker (CSW) services;

(vii) Services and supplies incident to the services of CPs and CSWs.

(B) Physicians' services.  In addition to the professional services of a physician, and services provided by an APRN, PA, and CNM which would be covered as RHC services under Medicare, certain primary preventive services are covered under the SoonerCare RHC benefit. The services must be furnished by or under the direct supervision of an RHC practitioner who is a clinic employee:

(i) Prenatal and postpartum care;

(ii) Screening examination under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program for members under twenty-one (21);

(iii) Family planning services;

(iv) Medically necessary screening mammography and follow-up mammograms.

(C) Services and supplies "incident to".  Services and supplies incident to the service of a physician, PA, APRN, CP, or CSW are covered if the service or supply is:

(i) A type commonly furnished in physicians' offices;

(ii) A type commonly rendered either without charge or included in the rural health clinic's bill;

(iii) Furnished as an incidental, although integral, part of a physician's professional services; or

(iv) Drugs and biologicals which cannot be self-administered or are specifically covered by Medicare law, are included within the scope of RHC services. Drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids are not billed separately.

(D) Visiting nurse services.  Visiting nurse services are covered if:

(i) The RHC is located in an area in which the Centers for Medicare and Medicaid Services (CMS) has determined there is a shortage of home health agencies;

(ii) The services are rendered to members who are homebound;

(iii) The member is furnished nursing care on a part-time or intermittent basis by a registered nurse, licensed practical nurse, or licensed vocational nurse who is employed by or receives compensation for the services from the RHC; and

(iv) The services are furnished under a written plan of treatment.

(E) RHC encounter.  RHC "core" services (including preventive services, i.e., prenatal, EPSDT, or family planning) are part of an all-inclusive visit. A "visit" means a face-to-face encounter between a clinic patient and an RHC health professional (physicians, PAs, APRNs, CNMs, CPs, and CSWs). Encounters with more than one (1) health professional and multiple encounters with the same health professional that takes place on the same day and a single location, constitute a single visit except when the member, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. Payment is made for one (1) encounter per member per day. Medical review will be required for additional visits for children. Payment is also limited to four (4) visits per member per month for adults.

(F) Off-site services.  RHC services provided off-site of the clinic are covered as long as the RHC has a compensation arrangement with the RHC practitioner that SoonerCare reimbursement is made to the RHC and the RHC practitioner receives his or her compensation from the RHC. The RHC must have a written contract with the physician and other RHC "core" practitioners that specifically identify how the RHC services provided off-site are to be billed to SoonerCare. It is expected that services provided in off-site settings are, in most cases, temporary and intermittent, i.e., when the member cannot come to the clinic due to health reasons.

(2) Other ambulatory services.  An RHC must provide other items and services which are not "RHC services" as described in (1) of this Section, and are separately billable within the scope of the SoonerCare fee-for-service (FFS) contract. Coverage of services are based upon the scope of coverage under the SoonerCare program.

(A) Other ambulatory services include, but are not limited to:

(i) Dental services for members under the age of twenty-one (21);

(ii) Optometric services;

(iii) Clinical lab tests performed in the RHC lab, including the lab tests required for RHC certification;

(iv) Technical component of diagnostic tests such as x-rays and EKGs (interpretation of the test provided by the RHC physician is included in the encounter rate);

(v) Durable medical equipment;

(vi) Transportation by ambulance [refer to Oklahoma Administrative Code (OAC) 317:30-5-335];

(vii) Prescribed drugs;

(viii) Prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags) and supplies directly related to colostomy care and the replacement of such devices;

(ix) Specialized laboratory services furnished away from the clinic;

(x) Inpatient services;

(xi) Outpatient hospital services; and

(xii) Applied behavior analysis (ABA) [refer to OAC 317:30-3-65.12].

(xiii) Diabetes self-management training (DSMT) (refer to OAC 317:30-5-1080 B 1084).

(B) Payment is made directly to the RHC on an encounter basis for on-site dental services by a licensed dentist or optometric services by a licensed optometrist for members under the age of twenty-one (21). Encounters are billed as one (1) of the following:

(i) EPSDT dental screening.  An EPSDT dental screening includes oral examination, prophylaxis and fluoride treatment, charting of needed treatment, and, if necessary, x-rays (including two bite wing films). This service must be filed on claim form ADM-36-D for EPSDT reporting purposes.

(ii) Dental encounter.  A dental encounter consists of all dental treatment other than a dental screening. This service must be billed on the ADM-36-D.

(iii) Visual analysis.  Visual analysis (initial or yearly) for a child with glasses, or a child who needs glasses, or a medical eye exam. This includes the refraction and medical eye health evaluation. Glasses must be billed separately. Payment is limited to two (2) glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.

(C) Services listed in(2)(A), (v)-(viii), of this Section, furnished on-site, require separate provider agreements with the Oklahoma Health Care Authority (OHCA). Service item (2)(A)(iii) does not require a separate contract when furnished on-site, however, certain conditions of participation apply. (Refer to OAC 317:30-5-361 for conditions.)

(D) Other ambulatory services provided off-site by independent practitioners (through subcontracting agreements or arrangements for services not available at the clinic) must be billed to the SoonerCare program by the provider rendering the service. Independent practitioners must meet provider eligibility criteria and must have a current contract with the OHCA.

 

317:30-5-356.Coverage for adults

[Revised 09-01-17]

Payment is made to rural health clinics for adult services as set forth in this Section.

(1) RHC services. Payment is made for one encounter per member per day. Payment is also limited to four visits per member per month. Refer to OAC 317:30-1, General Provisions, and OAC 317:30-3-65.2 for exceptions to the four visit limit for children under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). Additional preventive service exceptions include:

(A) Obstetrical care.  A Rural Health Clinic should have a written contract with its physician, certified nurse midwife, advanced practice nurse, or physician assistant that specifically identifies how obstetrical care will be billed to SoonerCare, in order to avoid duplicative billing situations. The agreement should also specifically identify the physician's compensation for rural health and non-rural health clinic (other ambulatory) services.

(i) If the clinic compensates the physician, certified nurse midwife or advanced practice nurse to provide obstetrical care, then the clinic must bill the SoonerCare program for each prenatal visit using the appropriate CPT evaluation and management codes.

(ii) If the clinic does not compensate its practitioners to provide obstetrical care, then the independent practitioner must bill the OHCA for prenatal care according to the global method described in the SoonerCare provider specific rules for physicians, certified nurse midwives, physician assistants, and advanced practice nurses (refer to OAC 317:30-5-22).

(iii) Under both billing methods, payment for prenatal care includes all routine or minor medical problems. No additional payment is made to the prenatal provider except in the case of a major illness distinctly unrelated to pregnancy.

(B) Family planning services.  Family planning services are available only to members with reproductive capability. Family planning visits do not count as one of the four RHC visits per month.

(2) Other ambulatory services.  Services defined as "other ambulatory" services are not considered a part of a RHC visit and are therefore billable to the SoonerCare program by the RHC or provider of service on the appropriate claim forms. Other ambulatory services are subject to the same scope of coverage as other SoonerCare services billed to the program, i.e., limited adult services and some services for under 21 subject to same prior authorization process. Refer to OAC 317:30-1, General Provisions, and OAC 317:30-3-57, 317:30-5-59, and 317:30-3-60 for general coverage and exclusions under the SoonerCare program. Some specific limitations are applicable to other ambulatory services as set forth in specific provider rules and excerpted as follows: Coverage under optometrists for adults is limited to treatment of eye disease not related to refractive errors. There is no coverage for eye exams for the purpose of prescribing eyeglasses, contact lenses or other visual aids. (See OAC 317:30-5-431.)

317:30-5-357.Coverage for children
[Revised 01-06-2020]

Coverage for rural health clinic (RHC) services and other ambulatory services for children include the same services as for adults in addition to the following:

(1) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are covered for eligible members under twenty-one (21) years of age in accordance with Oklahoma Administrative Code (OAC) 317:30-3-65. An EPSDT exam performed by an RHC must be billed on the appropriate claim form with the appropriate preventive medicine procedure code from the Current Procedural Terminology (CPT) manual. If an EPSDT screening is billed, an RHC encounter should not be billed on the same day. Refer to OAC 317:30-3-65 through 317:30-3-65.12.

(2) Under EPSDT, coverage is allowed for visual screenings and eyeglasses to correct visual defects. Payment is limited to two (2) glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.

(3) An EPSDT screening is considered a comprehensive examination. A provider billing the Medicaid program for an EPSDT screening may not bill any other visits for that patient on that same day. It is expected that the screening provider will perform necessary treatment as part of the screening charge. Additional services such as tests, immunizations, etc., required at the time of screening may be billed independently from the screening.

(4) The administration fee for immunizations should be billed if provided at the same time as a scheduled EPSDT examination.

(5) Payment may be made directly to the RHC for the professional services of physician assistants performing EPSDT screenings within the certified RHC. The claim form must include the signature of the supervising physician.

 

317:30-5-358.Vocational rehabilitation [REVOKED]
[Revoked 6-27-02]

317:30-5-359.Claims for Medicare eligible recipients
[Revised 7-1-02]
Payment is made to rural health clinics utilizing the Medicaid allowable for comparable services.

317:30-5-359.1.Cost reports
[Revised 11-14-95]
(a) Provider-based RHCs are required to report each RHC on a separate clinic line cost center on the Medicare Cost Report (HCFA 2552). A copy of the HCFA 2552, including the Medicaid Supplemental Worksheet S-2, is submitted to the OHCA as part of the year-end cost report process of the parent hospital. (Refer to OAC 317:30-5-48).
(b) Independent RHCs are required to submit to the OHCA a completed copy of the Medicare Cost Report for the annual cost reporting period (HCFA 222-92) within the due date for filing the cost report to the fiscal intermediary. Preventive services, i.e., prenatal, EPSDT and family planning visits, should not be counted in total visits in the Medicare cost report. The associated cost for the rural health clinic services covered by Medicaid only should be reported as a non-reimbursable cost on the clinic's Medicare cost report.
(c) If the clinic does not submit an adequate annual report on time, the OHCA may reduce or suspend payments to preclude excess payment to the clinic.

317:30-5-359.2.Reimbursement

[Revised 07-01-13]

(a) Provider-based clinics.  Interim payments for provider-based clinics will be made for RHC "core" services based on an all-inclusive visit fee established by reference to payments to other Rural Health Clinics in the same or adjacent areas or by cost reporting methods.  The interim rate for core services will be reviewed and revised as appropriate, based on cost data from an initial cost report.  Costs will be determined from the parent hospital's cost-to-charge ratios per the HCFA-2552 Medicare (or Medicaid, when filed) Worksheet C, Part 1, Computation of Ratio of Costs to Charges.  Lower of cost or charge provision will be calculated using the lesser of costs or two times charges (as determined by averaged cost to charge ratios based on FY 95 cost reports). After the initial year and the per visit rate are established, the rate will be updated annually by the increase in the MEI.

(b) Independent clinics.  Interim payments for independent clinics will be made for RHC "core" services based on the all-inclusive rate established by reference to payments to other Rural Health Clinics in the same or adjacent areas or by cost reporting methods. The interim rate for core services will be reviewed and revised as appropriate, based on cost data from an initial 12 month cost report and payments may be subject to adjustment at the end of the reporting period.  After the initial year and the per visit rate are established, the rate will be updated annually by the increase in the MEI. For clinics that offer "other ambulatory" services and preventive services, payment will be made on a reasonable charge basis in accordance with Medicaid fee schedule guidelines.

317:30-5-360.Payment rates [REVOKED]
[Revoked 11-14-95]

317:30-5-361.Billing

[Revised 09-01-17]

(a) Encounters.  Payment is made for one encounter per member per day. Medical review will be required for additional visits for children. Payment is also limited to four visits per member per month for adults. Rural health clinics must bill the combined fees of all "core" services provided during an encounter on the appropriate claim form. Claims must include reasonable and customary charges.

(1) RHC.  The appropriate revenue code is required. No HCPC or CPT code is required.

(2) Mental health.  Mental health services must include a revenue code and a HCPCS code.

(3) Obstetrical care.  The appropriate revenue code and HCPCS code are required. The date the member is first seen is required. The primary pregnancy diagnosis code is also required. Secondary diagnosis codes are used to describe complications of pregnancy. Delivery must be billed by the independent practitioner who has a contract with the OHCA.

(4) Family planning.  Family planning encounters require a revenue code, HCPCS code, and a family planning diagnosis.

(5) EPSDT screening.  EPSDT screenings must be billed by the attending provider using the appropriate Preventative Medicine procedure code from the Current Procedural Terminology Manual (CPT).

(6) Dental.  Dental services for children must be billed on the appropriate dental claim form.

(7) Visual analysis.  Optometric services for children are billed using the appropriate revenue code and a HCPCS code.

(b) Services billed separately from encounters.  Other ambulatory services and preventive services itemized separately from encounters must be billed using the appropriate revenue, HCPC and/or CPT codes. Claims must include reasonable and customary charges.

(1) Laboratory.  The rural health clinic must be CLIA certified for specialized laboratory services performed. Laboratory services must be itemized separately using the appropriate CPT or HCPCS code.

(2) Radiology.  Radiology must be identified using the appropriate CPT or HCPC code with the technical component modifier. Radiology services are paid at the technical component rate. The professional component is included in the encounter rate.

(3) Immunizations.  The administration fee for immunizations provided on the same day as the EPSDT exam is billed separately.

(4) Contraceptives.  Contraceptives are billed independently from the family planning encounter. A revenue code and the appropriate CPT or HCPC codes are required. The following are examples:

(A) DepoProvera 150 mg. (Medroxyprogesterone Acetate).

(B) Insertion and implantation of a subdermal contraceptive device.

(C) Removal, implantable contraceptive devices.

(D) Removal, with reinsertion, implantable contraceptive device.

(E) Insertion of intrauterine device (IUD).

(F) Removal of intrauterine device.

(G) ParaGard IUD.

(H) Progestasert IUD.

(5) Eyeglasses.  Eyeglasses prescribed by a licensed optometrist are billed using the appropriate revenue code and HCPCS code. Payment is limited to two eyeglasses per year. Any eyeglasses beyond this limit must be prior authorized and determined to be medically necessary.

317:30-5-362.Documentation of records
[Revised 11-14-95]
All services offered by a rural health clinic are to be furnished in accordance with applicable Federal and State laws and regulations. These requirements include written policies as to the description of the services the clinic furnishes directly and also those services provided by agreement or arrangement.
(1) a clinical record system, which includes documentation of all services provided to the patient, must be maintained in accordance with written policies and procedures, and be available to on-site reviewers upon request.
(2) records necessary to disclose the extent of services the provider furnishes to recipients, including those records as just described, and any information regarding payments claimed by the provider for furnishing services must be retained for a period of six years. The provider may, after one year from the date of service(s), microfilm or microfiche the records for the remaining five years.

317:30-5-363.340B Drug Discount Program
[Issued 09-12-14]
   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.