Budget latest; tips for PA approvals; holiday closings; fighting the flu; and more!

Budget latest; tips for PA approvals; holiday closings; fighting the flu; and more!

Having trouble viewing this email? View it as a Web page.

oklahoma health care authority provider checkup

Fall 2017, Vol. 2

Blue Divider

OHCA budget update

State budget issues continue to impact operations at the Oklahoma Health Care Authority

The Oklahoma Health Care Authority (OHCA) has called a special board meeting for Dec. 1 to recommend that the agency delay and reduce provider rate reductions which were approved on Nov. 9, 2017, and scheduled to go into effect Dec. 1, 2017. 

The agency received $22.8 million when Governor Mary Fallin approved sections of the appropriations bill on November 17. These funds will allow the agency to postpone and reduce the provider rate reductions until January 1.

In anticipation of the agency’s $70 million reduction to its appropriation due to the loss of the smoking cessation fee and in order to submit a balanced budget, the OHCA has already taken several budget balancing actions. First, the agency developed several program changes to be implemented in SFY18 that produced savings of approximately $3.2 million for SFY18. In addition, $4.65 million in 2017 general revenue was returned to the agency in 2018. The agency had $12 million in carryover from SFY17 to use. These combined savings equate to approximately $19.85 million.

On November 9, the OHCA board approved across-the-board provider rate reductions of 9 percent and 4 percent for nursing facilities as well as eliminating Medicare crossover coinsurance and deductible payments for nursing facilities to be effective December 1. These actions were taken to help cover the remainder of the $70 million base reduction.

However, with the receipt of the $22.8 million, the agency has scheduled a State Plan Amendment Rate Committee (SPARC) meeting and an emergency board meeting for December 1 to amend provider rate reductions. 

According to the SPARC meeting notification filed with the Office of Management and Enterprise Services, OHCA plans to submit across-the-board provider rate reductions of 6 percent (with exceptions) and 1 percent for nursing facilities as well as eliminating Medicare crossover coinsurance and deductible payments for nursing facilities to be effective January 1.

“The OHCA continues to work diligently to protect providers from rate reductions," said OHCA CEO Becky Pasternik-Ikard. "Reducing and delaying the rate reductions is part of that commitment. 

"However, while these funds have provided an immediate relief, even with the January 1 rate reductions, we are still approximately $9.5 million short of a balanced budget. We will continue to work with [state] leadership to try to find funding solutions that will fully fund the agency and possibly allow us to reverse these reductions.”

Back to top

OHCA programs on the line without Congressional action

The Oklahoma Health Care Authority (OHCA) wants to inform you of the possibility that if you have patients in Soon-To-Be-Sooners or who are covered under Insure Oklahoma Employer Sponsored Insurance (ESI) - Child, your patients might have changes in their eligibility in the coming months.

Funding for these programs comes from the Children’s Health Insurance Program (CHIP), which expired Sept. 30, 2017. CHIP is a federal program, and the U.S. Congress has until the end of the year to reauthorize it. As of the date of this letter, that reauthorization has not occurred.

The OHCA currently has enough CHIP funding to maintain through early 2018. After that time, however, these programs may be terminated and your patients could lose their eligibility if Congress does not reauthorize CHIP.

CHIP has been providing health coverage to eligible children and pregnant women since it was signed into law in 1997. The OHCA is hopeful the program will continue and that these program terminations can be avoided.

More information about CHIP and these programs is available at www.okhca.org/chip. If your patients have questions, please refer them to the website for the latest news and updates.

Back to top

provider notes

Contract renewals

A wheelchair is an example of DME

Expiration for DME contracts extended

The OHCA has amended its durable medical equipment and/or medical supplies (DME) contracts. This change allows DME providers who also have pharmacy contracts to have both contracts expire on the same date - June 30, 2018.

Please have your signatory authority sign the attached amendment and return it to OHCA Provider Enrollment as soon as possible. You can fax your amendment to 405-530-3224 or email it to ProviderEnrollment@okhca.org.

The OHCA will send you a fully-executed copy of the amended contract after it is received and signed by our agency representative.

If you have any questions regarding this change, please contact us at 800-522-0114, option 5.

Back to top

Provider services


Care coordination payment changes

As a reminder, effective Jan. 1, 2018, OHCA will only pay care coordination fees for members who have had a visit with their assigned provider. This includes Insure Oklahoma providers and their assigned members. 

On a monthly basis, the OHCA will look back 15 months to ensure providers receive care coordination for all established members aligned with their practice.           

For additional information regarding this change, please review our care coordination letter, available online.

Doctor welcomes patient at reception desk

Help decrease no-shows in your office

No-shows don't help our members or our providers. Now a new tool can help providers get patients on the road to recovery - literally! 

TripCare is a website offering a service to help providers get SoonerCare members in for care.

This service is provided by LogistiCare, which administers OHCA's long-standing SoonerRide program. SoonerRide lets SoonerCare members schedule non-emergency transportation to health care appointments for themselves. Alternatively, TripCare allows the provider to schedule the ride.

This service is at no cost to the provider; however, an EDI form is required to get started. 

Providers will receive a username and password after the EDI form is submitted to LogistiCare via fax at 1-800-597-2091.

Back to top

Top tips to increase your chance for PA approval

Happy medical team receives PA approval through the Provider Portal

Medical directors of the Oklahoma Health Care Authority (OHCA) review documentation attached to request for services in order to determine medical necessity. Comparison is then made to guidelines based on current standards of care and supported by evidence-based medicine reports. 

Documentation must connect the dots

Most often, the missing information that results in a prior authorization (PA) denial is an answer to the question “Why?”  

“Why is the requested service medically necessary?” If the request is for a repeat service in a short period of time, “Why does the service need to be provided at such a short interval?” If the request is for a repeat image, “Why was the initial image not adequate, or was it missing a needed part of the anatomy?”

Often the medical record includes minimal pertinent information in the patient history or physical exam supporting the request. Brief notes such as “echo” or “MRI of LS spine” are often all that is found upon reading the assessment and plan. Without sufficient information to connect the chief complaint and the plan - answering the “why?” - an approval is not possible. 

In reviewing records, as soon as information is found to support the criteria for approval, the request is approved and sent back to the provider.  The mindset of the review is to find criteria for approval.  A clear answer to the “Why?” makes approval easy.

Medical documentation must be legible

With the advent of electronic medical records, the vast majority of records are easily legible. However, the OHCA still receives a significant number of handwritten medical records.  While many of them are easily legible, those that are not, automatically result in a denial of service. 

An illegible record cannot be evaluated. The external note attached to the file at the time of denial, which is visible on the Provider Portal, will note the reason for denial as “illegible records” to help the provider.

Resubmitting the same files will not help. If the record is partially legible, and enough information can be read to satisfy the requirements for approval, the service will be approved. However, limited resources and quantity of reviews does not permit extended time attempting to decipher illegible text.

MD-DDS.Inquiries@okhca.org is available for questions addressed to the OHCA medical directors regarding prior authorization approvals or denials. This email address is available only to contracted MD, DO, DDS, APRN and PA providers and is monitored in real time from 8 a.m. to 5 p.m. weekdays.

This email is not available to anyone other than the medical professionals listed above. Emails should not be written by office or nursing staff, and content should be limited to topics related to PA decisions.

The OHCA wishes to thank all providers who provide medical care to our members.

Medical Professional Services webpage at www.okhca.org/mps

Back to top

Agency closings

The OHCA would like to announce its holiday schedule for the period December 2017 through January 2018. 

  • Dec. 25-26, 2017 – Christmas Holiday
  • Jan. 1, 2018 – New Year’s Day
  • Jan. 15, 2018 – Martin Luther King, Jr. Day

Thank you for understanding.

Back to top


Treating diabetes

The American Diabetes Association® has established November as American Diabetes Month® to increase public awareness and improve care for patients with diabetes, but patients and their families feel the impact of the disease every day. Recent reports show nearly 1 in 11 Americans have diabetes, and 1 in 3 has prediabetes.(1)

Since 2004, Oklahoma has been consistently above the national average for number of adults with diabetes.(2) Since 2014, anti-diabetic agents have been one of the top ten most prescribed medications for Oklahomans insured through SoonerCare.(3)

To assist providers in their care of diabetes, the ADA has published an updated Standards of Medical Care in Diabetes.(4) The abridged position statement is available on the ADA’s Diabetes Pro website (https://www.professional.diabetes.org).  

Pharmacological therapy recommendations for patients with type 2 diabetes are summarized in the following chart:

Pharmacological therapy recommendations for patients with type 2 diabetes, Part 1
Pharmacological therapy recommendations for patients with type 2 diabetes, part 2

In addition to the ADA recommendations, statements pertaining to treatment of diabetes have recently been published by the United States Food & Drug Administration (FDA).

  • Pioglitazone, a thiazolidinedione (TZD) may increase the risk of bladder cancer and should be avoided in patients with active bladder cancer. Providers should carefully consider the benefits and risks for TZD use in patients with a history of bladder cancer.5
  • Certain dipeptidyl peptidase-4 inhibitors (DPP-4-i), saxagliptin and alogliptin, may increase the risk of heart failure, particularly in patients with existing kidney disease. Providers should consider discontinuing these medications if patients develop heart failure.6
  • Metformin has a revised label due to studies related to its use in patients with impaired kidney function. An assessment of kidney function is recommended before initiation of metformin therapy, and at least annually thereafter. Metformin is contraindicated for patients with eGFR ≤ 30 mL/min and initiation is not recommended with eGFR between 30-45 mL/min. If, after initiation, eGFR falls below 45 mL/min, risks and benefits must be assessed. Additional considerations exist surrounding the use of iodine contrast media.7
  • Canagliflozin, a sodium-glucose cotransporter 2 inhibitor (SGLT2-i), is associated with increased risk of leg and foot amputations, primarily affecting the toes. Providers should monitor, and advise patients to self-monitor, for any new pain or tenderness, sores or ulcers, or infections in their legs or feet.8

To view the anti-diabetic agents covered through SoonerCare, please visit the OHCA website (www.okhca.org).  



  1. Statistics about diabetes, American Diabetes Association. Available at http://www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav. Accessed November 1, 2017.
  2. Age-adjusted percentage, adults with diabetes – Total, 2015. Available at https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html. Accessed November 1, 2017.
  3. Oklahoma Health Care Authority, DUR Board Packet, April 12, 2017. Holderread B. Available at https://www.okhca.org/about.aspx?id=490. Accessed November 1, 2017.
  4. American Diabetes Association Position Statement: Standards of Medical Care in Diabetes—2017. Diabetes Care 2017;40(Suppl. 1):S1–S138. Available at: https://professional.diabetes.org/sites/professional.diabetes.org/files/media/abridged_standards_of_medical_care_in_diabetes_2017_0.pdf. Accessed November 1, 2017.
  5. FDA Drug Safety Communication: Updated FDA review concludes that use of type 2 diabetes medicine pioglitazone may be linked to an increased risk of bladder cancer. December 2016. Available at: https://www.fda.gov/Drugs/DrugSafety/ucm519616.htm. Accessed November 1, 2017.
  6. FDA Drug Safety Communication: FDA adds warnings about heart failure risk to labels of type 2 diabetes medicines containing saxagliptin and alogliptin. April 2016. Available at: https://www.fda.gov/Drugs/DrugSafety/ucm486096.htm . Accessed November 1, 2017.
  7. FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. April 2017. Available at: https://www.fda.gov/Drugs/DrugSafety/ucm493244.htm . Accessed November 1, 2017.
  8.  FDA Drug Safety Communication: Interim clinical trial results find increased risk of leg and foot amputations, mostly affecting the toes, with the diabetes medicine canagliflozin (Invokana, Invokamet); FDA to investigate. May 2017. Available at: https://www.fda.gov/Drugs/DrugSafety/ucm500965.htm . Accessed November 1, 2017.

Back to top


Dental program update

The OHCA promulgated emergency rules that were approved by the OHCA Board on September 27, 2017. These rules include adult dental emergency extractions, which received gubernatorial approval on October 6, 2017. The adult dental emergency extractions rule went into effect on November 1, 2017.

Adult Dental Emergency Extractions

Dental policy at OAC 317:30-5-696 is updated to amend the rule that limits dental services for adults to “emergency” extractions. The policy was initially intended for emergency extractions and was later revised to medically necessary extractions. The intent of the change was to ensure the emergency extractions were medically necessary; therefore, the policy reverts to the original language to include the term emergency along with reference to where emergency dental care is defined in policy.  The proposed revisions also add new language on the medically necessary images and oral examination that can accompany an emergency extraction.

The OHCA encourages you to review each rule change in its entirety. If you have any questions regarding this rule change, please call the OHCA Provider Helpline at 1-800-522-0114.

Back to top

OHCA's Rucker named Nurse of the Year

Anataya Rucker, OHCA Money Follows the Person Nurse Supervisor

OHCA Money Follows the Person Nurse Supervisor Anataya Rucker was recently honored by the March of Dimes at the annual Nurse of the Year Awards. Rucker took top honors in the Managed Care category.

Through Nurse of the Year Awards, the March of Dimes recognizes nurses who demonstrate exceptional patient care, compassion, and service and play a critical role in improving the health of Oklahoma’s residents.

Rucker was among 18 outstanding nurses to be recognized for her service. 2017 honorees were selected by a distinguished committee of fellow nurses, also well-accomplished and leaders in their respective professions.

Funds raised by the Nurse of the Year Awards support research and other programs that help moms have full-term pregnancies and healthy babies. Funds are also used to bring support and resources to families whose babies are born sick or too soon.

Back to top

Stick it to the flu!

Smiling boy receiving vaccine

The fall and winter months are peak times for the flu in the United States, particularly between December and February. However, it is not uncommon for flu season last as late as May.

Safeguarding our communities from the flu is important. Flu vaccinations help keep us healthy, thereby reducing  the number of doctors’ visits, missed work and school days, as well as prevent flu-related hospitalizations and even death.

Health care providers should talk to their patients and/or their guardians about receiving the flu vaccine if they have not already gotten one. Providers should also read up on the latest flu vaccine administration guidelines to dispense the adequate vaccine for the patient, as some populations require two doses of vaccine or higher strengths.

The Centers for Disease Control and Prevention (CDC) has a wealth of provider resources online regarding the 2017-2018 influenza season, including primary changes to the Advisory Committee on Immunization Practices (ACIP) recommendations for seasonal flu vaccines. The OHCA encourages providers to visit the CDC online at www.cdc.gov.

Remember - The more people are vaccinated, the more people are protected from flu.

Did you know?

December 3-9, 2017, is National Influenza Vaccination Week?

Health care providers can take advantage of a free CDC Digital Media Toolkit to help promote flu vaccination in their practices. Resources include printable flyers, social media messages and more.

Back to top

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


December 1
OHCA Board Meeting (special)

December 13
Drug Utilization Review (DUR) Meeting

December 14
OHCA Board Meeting

January 10
DUR 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.