Budget plan; rule changes approved; ADHD meds update; free food for kids; and more!

Budget plan; rule changes approved; ADHD meds update; free food for kids; and more! 

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oklahoma health care authority provider checkup

Summer 2017

Blue Divider

OHCA board approves budget plan

The word "budget" under a magnifying glass

The Oklahoma Health Care Authority (OHCA) board approved the agency’s state fiscal year (SFY) 2018 budget work program during their June 29 meeting, noting that in all likelihood, it will need to be amended during the year.

“Our agency was fortunate that state leadership tried to hold our appropriations as level as possible," said OHCA CEO Becky Pasternik-Ikard. "We appreciate their efforts.” 

The agency requested $69 million above last year’s base in order to maintain the program at the SFY17 level. The increase was needed mainly due to declining federal matching funds. While the agency was appropriated an increase, it was about $35 million less than the $69 million that was needed.

To accommodate the shortfall, OHCA plans to push a claim run from June 2018 into SFY19, which begins July 1, 2018. The agency normally pays its providers on a weekly basis, making 52 claim runs per year. 

The agency is also faced with the possibility that the federal government will not vote to reauthorize the enhanced federal matching dollars which were approved through the Affordable Care Act (ACA) for the Children’s Health Insurance Program (CHIP). A vote on the measure is expected this fall. Should the enhanced CHIP funding not be reauthorized, the agency stands to lose about $50 million in federal funds in SFY18. To accommodate for this loss in funding and to file a balanced budget, the agency plans to push two additional claim runs into July 2018 meaning the agency will make 49 payment cycles to providers in SFY18 as opposed to the regular 52 runs.

“We will certainly be monitoring activities at both the state and federal levels,” Pasternik-Ikard said. “Should Congress reauthorize the enhanced CHIP funding, we will bring needed adjustments back to the board as soon as possible.”

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Get ready for Fall Training Workshops

Sign reads, "Training just ahead"

You and your staff are invited to attend the fall 2017 SoonerCare Provider Training Workshops hosted by OHCA and HP Enterprise Services.

  • Lawton            September 28
  • Durant             October 5
  • Tulsa               October 11 - 12
  • OKC                October 25 - 26
  • Guymon          TBA

OHCA highly recommends that all providers attend a workshop in their area. Mark your calendar today!  

Class descriptions and registration details will post to the provider training page of our website when they are available.

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provider notes

Contract renewals

Contract renewals are underway for the following provider types:

  • Dentist
  • Genetic counselor
  • Independent diagnostic testing facility
  • Independent lab
  • Lactation consultant
  • Maternal and infant health licensed clinical social worker
  • Room & board

Contracts for these providers expire Sept. 30, 2017. We encourage you to start the re-enrollment process as soon as possible through the secure OHCA Provider Portal.


OHCA would like to remind you that all required documents for contracts must be uploaded and received by OHCA no more than 30 days from the date of submitting your contract. This completion requirement applies to new contracts as well as renewals.

We appreciate your cooperation. 

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Provider services

Referral Process Change

Beginning Sept. 1, 2017, electronic referrals through the SoonerCare Provider Portal will no longer be available for SoonerCare Choice medical homes or Insure Oklahoma (PUB) providers. This change will give providers flexibility to adopt a referral process that works better for their individual practices.

Claims submitted on or after September 1 will no longer require an electronic referral, and providers may begin using alternative referral methods. As an option, an updated paper referral form (SC-10) will be made available.

For full details regarding this change, please refer to Provider Letter OHCA 2017-09 found at www.okhca.org/providerletters.

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Policy and programs

Rules and regulations

2017 Permanent rules approved

Gov. Mary Fallin signed and certified the OHCA’s 2017 permanent rule changes on June 13, 2017. All policy changes are effective Sept. 1, 2017, and will post to the policy webpage on that date. 

A total of 34 permanent rules were approved. Rule changes include: 

  • Indian health services, tribal program and urban Indian clinics (I/T/Us) and federally qualified health centers policy at OAC 317:30-5-660.3, 317:30-5-661.4, 317:30-5-664.1, 317:30-5-1087, 317:30-5-1090, 317:30-5-1094, and 317:30-5-1098 is amended to remove the minimum 45-50 minute time requirement for outpatient behavioral health encounters. Rules are also added to indicate that behavioral health services must be billed on an appropriate claim form using appropriate Current Procedural Code (CPT) and guidelines. In addition, rules clarify that prescription drugs are now billed pursuant to the changes made to our Chapter 30 rules that adhere with federal guidelines. Those changes modified the pharmacy pricing methodology and now allow I/T/U pharmacies to be reimbursed at the Federal Office of Management and Budget (OMB) encounter rate. Further, revisions reference an updated section of policy related to home health services that now require a face-to-face encounter prior to the ordering of services. Lastly, revisions replace the term “telemedicine” with “telehealth” to be more inclusive of an array of telehealth technologies that could potentially be used to deliver health care services to SoonerCare members.(Reference APA WF # 16-23)
  •  Dental policy at OAC 317:30-5-696, 317:30-5-698 and 317:30-5-700.1 adds language allowing dental providers to submit the diagnostic cast or photographic images as evidence of medical necessity for dental services. The procedure is a necessary part of many dental practices, including orthodontics, and the change allows providers to bill for a necessary service. In addition, revisions add the term "certified" to nurse midwife to mirror terminology used by the Oklahoma Nursing Board.
    (Reference APA WF # 16-34)
  •  Program Integrity Audits/Reviews policy at OAC 317:30-3-2.1, 317:30-3-4.1 and 317:30-3-30 is revised to clarify the OHCA audit process by: explaining that the scope of audits may include examination for fraud, waste, and/or abuse of the SoonerCare program; establishing a clearly defined response due date for providers who want to request an informal reconsideration and/or formal appeal of audit findings; and by informing providers that overpayments identified through the audit process may be withheld from future payments if the provider fails to timely contest the underlying audit findings. Also, proposed revisions in Uniform Electronic Transaction Act set a consistent timeframe in which to authenticate medical records. This includes those instances in which transcription occurs. Finally, revisions improve reader comprehension and make the language consistent with other OHCA administrative rules.
    (Reference APA WF # 16-36)

Providers will receive complete details on all 2017 permanent rule changes in the next few weeks.

Proposed state plan amendment

A proposed state plan amendment (SPA) will revise coverage language to increase access and utilization of long-acting reversible contraceptives (LARC) devices.

The proposed SPA will expand access to these devices by removing unnecessary restrictions. Changes within the proposed SPA will support appropriate birth spacing, which can reduce infant and maternal mortality. 

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Provider checks PA on his computer

Have you noticed recent changes in some Oklahoma Health Care Authority (OHCA) product-based prior authorization (PA) categories? 

OHCA periodically implements PA changes due to multiple factors including, but not limited to, manufacturer availability, approved indications, published guidelines, and pricing considerations. OHCA makes every effort to provide multiple Tier-1 options whenever possible. The Tier-1 medications have well-documented clinical efficacy and are the most cost-effective option. Higher-tiered medications cost considerably more without demonstrating significantly greater clinical outcomes than Tier-1 options.

Members who do not achieve a clinical success with Tier-1 medication trials may qualify to obtain a higher-tiered medication. Trial criteria are different for each medication class. You can access them here.

A link to the PA form (PHARM-04: Petition for Medication Prior Authorization) is below each explanation of PA criteria. Using this form is the most effective method for submitting PA requests.

It is important to note that some medications have their own specific form (in place of PHARM-04). You can download these forms from the OHCA website at www.okhca.org/forms. Multiple software platforms have been created with the intention of expediting and streamlining the PA process. However, these programs do not interface well with the OHCA system and usually do not include the information necessary to complete the PA process.  

The vast majority of electronic health record or electronic medical record (EHR/EMR) programs also have embedded OHCA medication tier information in their electronic prescribing software package (E-script). Prescribers are able to quickly identify medications that will require a PA and those that are available as a Tier-1 medication. If your E-script package does not provide current OHCA tier information, please contact your EHR/EMR vendor. 

If a member completes a Tier-1 trial, as described for the medication class, the claim for the next highest tier in many cases will process without a PA. Alternately, patient-specific, clinically significant information is necessary for approval of a higher tiered medication. Some examples of patient-specific, clinically significant criteria include:

Examples of patient-specific, clinically significant criteria

Providers and/or staff may request additional information and receive personalized, medication-related PA training by contacting Jacki Travers, Pharm.D., by phone at 405-271-5935, or by email at jacki-travers@ouhsc.edu

ADHD medications PA criteria and tier chart changes

On July 12, 2017, the OHCA Drug Utilization Review (DUR) Board voted to prior authorize Vyvanse® for the treatment of ADHD in children and for treating moderate-to-severe binge eating (BED) in adults. 

In addition, the DUR approved updates to the ADHD PA criteria and tier chart. Effective Aug. 1, 2017, the following requirements apply to the ADHD medications product-based prior authorization (PBPA) category:

1. Place Vyvanse® (lisdexamfetamine chewable tables) into Tier-1 based on net cost after rebates.

a. Current Tier-1 criteria will apply.

b. A quantity limit of 30 chewable tablets per 30 days will apply.

c. Vyvanse® capsules and chewable tablets have currently provided a supplemental rebate to be placed in the Tier-1; however, Vyvanse® capsules and chewable tablets will be moved to a higher tier based on net cost in comparison to other available products if the manufacturer chooses not to participate in supplemental rebates.

2. Move Aptensio XRTM (methylphenidate ER capsules), generic Metadate CD® (methylphenidate ER capsules), and generic Ritalin LA® (methylphenidate ER capsules) into Tier-1 based on net cost after rebates. Metadate CD® and Ritalin LA® will no longer be brand preferred.

a. Current Tier-1 criteria will apply.

b. Aptensio XRTM capsules have currently provided a supplemental rebate to be placed in the Tier-1; however, Aptensio XRTM capsules will be moved to a higher tier based on net cost in comparison to other available products if the manufacturer chooses not to participate in supplemental rebates.

3. Move Quillivant XR® (methylphenidate ER suspension) and QuilliChew ERTM (methylphenidate ER chewable tablets) to Tier-2 based on net cost after rebates.

a. Current Tier-2 criteria will apply

b. Quillivant XR® suspension and QuilliChew ERTM tablets will have an age restriction of 10 years and younger. Members older than 10 years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.

c. Quillivant XR® suspension and QuilliChew ERTM tablets have currently been placed in Tier-2 based on net cost; however, if the net cost changes, Quillivant XR® suspension and QuilliChew ERTM tablets will be moved to a lower or higher tier based on net cost in comparison to other available products.

4. Move generic Metadate ER® (methylphenidate ER tablets), generic Methylin ER® (methylphenidate ER tablets), and generic Ritalin SR® (methylphenidate ER tablets) into Tier-3 based on net cost after rebates.

a. Current Tier-3 criteria will apply.

5. Add a previously failed trial of Nuvigil® (armodafinil) for authorization of Provigil® (modafinil), due to significantly lower net cost of Nuvigil® after rebates.

The following tier chart reflects these changes:

ADHD Tier Chart, July 2017

Additional details on these PA and tier changes are available in the Pharmacy PA section of the OHCA website.

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New at OKHCA.org

Checkups for SoonerCare kids on the rise

Doctor gives thumbs up on girl's well-child exam

More children covered under SoonerCare (Oklahoma Medicaid) are receiving preventive health screenings, according to the Oklahoma Health Care Authority’s (OHCA) annual report on childhood screenings to the Centers for Medicare & Medicaid Services (CMS).

Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, SoonerCare members under the age of 21 can receive annual preventive screenings, including developmental checks, immunizations, blood lead tests, and vision, hearing and dental screenings. 

In its 2016 Annual EPSDT Participation Report (CMS) to CMS, OHCA data showed that during federal fiscal year 2016, EPSDT participation increased an average of 2.6 percent from the previous year for all children under the age of 21.

Read more 

Agency cancels managed care RFP

The Oklahoma Health Care Authority took action on June 14, 2017, to cancel the request for proposal (RFP) for SoonerHealth+, the fully capitated, statewide model of care coordination that has been in development for Oklahoma Medicaid’s aged, blind and disabled (ABD) population. This decision was made in the best interest of the state due to the uncertainty surrounding both federal and state funding.  

House Bill 1566 passed by the Oklahoma Legislature and signed by Gov. Mary Fallin in April 2015 directed the OHCA to initiate an RFP for a care coordination model for the ABD population. This RFP was issued in November 2016.

“In addition to the funds needed to maintain services at current levels, the agency requested approximately $52 million to fund the care coordination model. The additional request was not funded; therefore, the agency is unable to move forward with the RFP,” said OHCA CEO Becky Pasternik-Ikard.

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OHCA uses tech to connect

Close-up of cellphone in woman's hand

In January 2015, OHCA partnered with George Kaiser Family Foundation and Wellpass (formerly Voxiva) to provide customized preventive health and administrative information to SoonerCare members via mobile messaging. The two-year contract immediately followed the Centers for Medicare & Medicaid Services (CMS) Text4baby pilot project to expand the target population to include SoonerCare members of all ages.

Reaching members where they are
OHCA began to allow SoonerCare members (pregnant women, caregivers of SoonerCare members ages zero through 18, and adult SoonerCare members) to enroll in the Connect4Health program in July 2016. Connect4health sends text messages customized by OHCA staff to promote targeted preventive health benefits, EPSDT and well-child visits, immunizations, medication compliance, appropriate ER utilization, SoonerCare application renewal reminders and more on behalf of SoonerCare. 

In January 2017, OHCA began automatically enrolling all SoonerCare members into Connect4health who provide consent through the SoonerCare online enrollment application.

The May 2017 Connect4Health report reveals:


•         Cumulative Enrollment for Connect4health programs- *111,744

o   *This figure represents the total number of households rather than individuals

•         Cumulative Text4health users- 49,558

•         Cumulative Text4kids users- 64,715

•         Cumulative Text4baby users- 12,428


•         Text4health (adult population) - 63% retention rate 10 months after enrollment

•         Text4kids (caregivers of children 1-18 years) - 88% retention rate 8 months after enrollment

•         Text4baby (pregnant women and >1 year) - 41% retention rate 10 months after enrollment

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Staff news

Chief dental officer retires

OHCA Chief Dental Officer Leon Bragg, D.D.S., retired on July 13, 2017. His retirement concludes 15 years of service with the state of Oklahoma.

Dr. Bragg became the OHCA’s first full-time dentist on Feb. 23, 2004. In this position, Dr. Bragg helped develop program policy for dental care for SoonerCare members, established benefits standards for quality, and assisted with utilization review for the program. He also served as a liaison between OHCA and its dental providers.

Gov. Mary Fallin recognized these accomplishments with a special commendation. OHCA also honored Dr. Bragg for his years of service to the agency with a commemorative award.

In addition to his role at OHCA, Dr. Bragg has been active in numerous local, state and national dental organizations. Most recently, Delta Dental of Oklahoma recognized Dr. Bragg for his service and leadership as president of the national Medicaid Medicare CHIP (Children's Health Insurance Program) Services Dental Association (MSDA).

Prior to his OHCA employment, Dr. Bragg maintained a private practice for more than 20 years in northeast Oklahoma City.  Later, he served as faculty at the University Of Oklahoma College Of Dentistry.

From left – Bragg with OHCA Chief Medical Officer Mike Herndon, July 13, 2017 

Dr. Leon Bragg with OHCA Chief Medical Officer Dr. Mike Herndon

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Evans honored for lifetime achievement

OHCA Sr. Medical Director Dr. Robert Evans recently received the Lifetime Achievement Award from the Oklahoma Ambulance Association (OKAMA). The group recognized Evans during their 2017 spring conference.

The award is inscribed “for a lifetime of achievement dedicated to improving” and was presented for 45 years of dedication to the development and improvement of Emergency Medical Services in three states.

Evans was originally trained as a basic EMT in 1972 and Registry in 1973, the second year of existence of the National Registry of EMTs. His work experience includes time as an EMT in Iowa as well as Kansas. Evans also trained future EMTs as an instructor at both the University of Iowa and the University of Kansas.

From left – Greg Reid, NRP, Robert Irby, NRP, Rebecca Williamson, RN, NRP and president of OKAMA, and Evans.

From left – Greg Reid, NRP, Robert Irby, NRP, Rebecca Williamson, RN, NRP and president of OKAMA, and Evans. (Photo courtesy of OKAMA) 

He moved to Oklahoma City in 1979 to become the director of the EMS program at Oklahoma City Community College (7/79 – 7/85) with responsibilities for developing the curricula and training materials for a new four-level certification program that had been passed by the legislature. Its purpose was to allow mostly rural areas of Oklahoma to develop EMS capabilities in their services as far as their personnel and resources would allow. An extant associate degree program was also modified to accommodate the new 4-level program. Full-time and part-time faculty worked under Evans direction to develop competency based curriculum materials, competency based skills labs and some individually paced training courses.

While in this capacity he served on the AMCARE (old ambulance service in OKC) medical advisory board and completed a Master of Education, Instructional Design at OU.  Early in his tenure in this position he certified with the National Registry of Paramedics.

Evans enrolled in Medical School in 1985, working part time for the ambulance service in Shawnee, Okla., and teaching part time at OCCC throughout medical school. 

After completing residency in anesthesiology, Evans practiced clinically until recently. During his clinical practice, he supervised clinical experience for many EMS students.

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Don’t let our children go hungry!

Small group of children eating sandwiches

Studies show that children who suffer from hunger often experience poorer health and school performance than those who have access to healthy foods. Unfortunately, child hunger is worse during the summer in Oklahoma, when school-year meal programs are not available. However, the U.S. Department of Agriculture’s summer feeding program is here to help!

Kids 18 and under can eat free at the more than 600 sites across the state. There are no sign-ups, red tape or paperwork required, and there is no limit on meals (which may include breakfast, lunch and even a snack).

You can even text FOOD to 877877 to receive a text back with listing the three nearest sites, their hours of operation, and meals served.

Dates and meals vary from site to site. Visit sde.ok.gov and click on the #FoodforThought banner to connect hungry children to free meals today!

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SoonerCare nutritional services for your patients

Adults and children can have up to six hours of nutritional counseling per year by a licensed registered dietitian; benefits differ slightly.Click here for more details. 

Nutritional services must be prescribed by a physician, physician assistant, advanced practice nurse or nurse midwife to be covered by SoonerCare. Click here to see a map of registered dieticians contracted with SoonerCare to which you may refer your patients. 

We encourage our medical home providers to discuss this option with members when deemed medically necessary. 

For questions or more information about this benefit, please contact your SoonerCare provider representative at 800-522-0114.  

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provider toolkit

OHCA Provider Helpline: 800-522-0114

Provider Resources

Web Alerts

Online Training

Order Publications

Statistics and Data

Newsletter Archive

Provider Reimbursement Notices

appointment reminders


July 20
Medical Advisory Committee (MAC) Meeting

August  24
OHCA Board Meeting

September 13
Drug Utilization Review (DUR) Board Meeting

View complete OHCA calendar here

checkup statement

Information contained within is subject to change. Be sure to check OHCA Provider LettersGlobal Messages and Web Alerts at www.okhca.org for the most up-to-date information.