OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page


317:25-7-29.Screening, diagnosis and preventive benefits
[Revised 01-01-09]

(a) The PCP is responsible for coordinating or delivering preventive and primary care services which are medically necessary to all SoonerCare members enrolled with him/her.

(b) School and health department clinics may conduct EPSDT screening examinations on children who have not been screened by their PCP pursuant to the EPSDT periodicity schedule. If it is ascertained that a child is not current, the school or health department clinic must first contact the PCP and attempt to set up an appointment for the child within three weeks.  If the PCP cannot meet this condition, the clinic will be permitted to conduct the screen and bill fee-for-service.

(1) The school or health department clinic must submit a claim for reimbursement, as well as documentation that:

(A) the PCP was contacted and an examination could not be conducted by the PCP within the specified guidelines; and

(B) the PCP has forwarded information for the patient file regarding the diagnosis, services rendered and need for follow-up. This documentation must be returned to the child's record for verification that PCPs have first been contacted and that school and health department clinics are providing PCPs with the information necessary to ensure continuity of care.

(2) The school-based clinic or health department must conduct the screening examination within three weeks from the date the determination was made that the PCP could not conduct the exam within the specified guidelines.



317:25-7-30.Obtaining SoonerCare services
[Revised 01-01-09]
(a) Medical services which are not the responsibility of the PCP to authorize under the care coordination component of SoonerCare, as described in OAC 317:25-7-10(b), are obtained in the same manner as under the regular SoonerCare fee-for-service program.
(b) Authorization for out-of-state transportation for primary care and specialty care is determined by the OHCA Medical Director.
(c) An eligible SoonerCare member may choose a PCP from the provider directory, including the IHS, tribal and Urban Indian clinics that participate as SoonerCare PCPs. The member needs to have the Certified Degree of Indian Blood information in order to enroll. An American Indian member in SoonerCare may enroll with a PCP who is not an IHS, tribal, or urban Indian clinic and still use the IHS, tribal or urban Indian clinic for medical care. A referral from the PCP is needed for services that the clinic cannot provide, except for self-referred services.
(d) If an IHS, tribal or urban Indian clinic is unable to deliver a service to a SoonerCare enrollee and must refer the member for the service to a non-IHS, tribal or urban Indian clinic, SoonerCare reimbursement is made only when the service is referred by the PCP, unless PCP authorization is not required under OAC 317:25-7-10(b).
(e) The PCP is not obligated to provide emergency services and is not responsible for authorization or approval for payment for members seen in the emergency room. The PCP may not require members to seek prior authorization for emergency services. However, the PCP may provide emergency care in an emergency setting, within his/her legal scope of practice.
(f) Some outpatient procedures require prior authorization. The PCP is responsible for obtaining a list before an outpatient procedure is done.


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.