Sound off on Medicaid community engagement requirements. Details inside!

Feedback wanted on Medicaid community engagement requirements; NOTICE: SoonerCare payment changes; a look at suicide prevention; and more!

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Summer 2018

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Drug pricing initiative approved - First in nation

The OHCA was notified June 27, 2018 that their proposal to become the first state Medicaid agency to move forward with negotiating value-based or outcomes-based contracts with pharmaceutical companies was approved by the federal government.

“In essence, this means that if a drug does not perform as claimed, the manufacturer will rebate the cost of the drug or another negotiated amount," said OHCA Pharmacy Director Nancy Nesser. "For example, if a drug claims to keep people out of the hospital and doesn't, the manufacturer may be liable for the cost of the hospitalization.”

Value-based contracts tie provider payments to successful clinical outcomes and effectiveness rather than simply paying for the medication. Rising prescription drug costs is one of the catalysts for the OHCA to find innovative ways to reduce Medicaid costs.

>>Read more. 

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OHCA enters into premier partnership to improve Medicaid outcomes

Illustration of hands shaking in agreement

On June 6, 2018, the Oklahoma Health Care Authority (OHCA), Pharmacy Management Consultants* (PMC) and Amgen (NASDAQ:AMGN) announced a new collaborative agreement to help improve clinical outcomes, experience and satisfaction for 796,000 SoonerCare members. Results from the projects could also lay the groundwork for innovative ways to look at patient outcomes and measures for medication reimbursement.

“I look forward to this collaboration providing valuable insights that will help improve patient outcomes and save money,” said Nancy Nesser, J.D., Pharm.D., OHCA Pharmacy director. “It fully aligns with our goal to foster collaboration among public and private individuals and entities to build a responsive health care system for Oklahoma.”


Amgen’s first public-private partnership with a state Medicaid agency to help improve patient health care needs through data, science and information


  AMGEN logo

The parties intend for initial research projects to use de-identified claims data to gain insights about medication adherence, missed diagnoses, heightened disease risk and other clinical indicators in Oklahoma’s SoonerCare population. Disease states of special interest to each participant include autoimmune diseases, bone health/osteoporosis, migraine and oncology care. The expectation is that findings from the research will help support the development of preventive measures – for instance, identifying post fracture patients and working to educate them on the importance of disease management. In many cases, the cost of preventive therapy is a fraction of the cost of hospitalization, and valuable to the patient’s health and well-being. Collectively, this information can help optimize overall patient outcomes and minimize unnecessary healthcare spending across the country.

>>Read more.

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Provider Notes

Provider services

Changes to your direct deposits

finger presses green computer key marked "Electronic Funds Transfer"


Effective Aug. 1, 2018, OHCA will implement a change to the addenda record attached to your EFT (direct deposit) payment. This change is to comply with HIPAA-mandated health care EFT standards. It will not affect the EFT payment itself. 


The current addenda record for payments made by SoonerCare:


Will become:


(TRN *1* + warrant [payment] number +*1, followed by OHCA’s Federal Tax ID Number [no dash] + *)  

PLEASE NOTE: It is important that you contact the financial institution where your SoonerCare payments are deposited to notify them of this upcoming change. Doing so will help to ensure your EFT payments received beginning August 1 will process properly and will not delay your funds availability.

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Looking ahead: Fall training dates

You and your staff are invited to attend the fall 2018 SoonerCare Provider Training Workshops hosted by OHCA and DXC.

  • Lawton - September 27    
  • Durant - October 4
  • Tulsa - October 10 and 11
  • Guymon - October 17
  • OKC - October 24 and 25

OHCA and DXC highly recommend that all providers attend this workshop. Be sure to mark your calendar! 

We will release class descriptions, recommended audiences and registration details soon. Please visit the provider Training page of our website for updates.

Free resources for your patients

OHCA offers several free publications that feature SoonerCare and Insure Oklahoma programs. These publications can be downloaded individually or providers may order a quantity to be delivered to them.

Our Medically Fragile brochure has been updated and is now available. We also restocked our SoonerRide magnets, Lock-in Program cards, Online Enrollment business cards and Insure Oklahoma brochures. They are available for order, while supplies last.

To order, download or view other helpful resources for your patients, visit our Publications Store.

  Photo of OHCA's Medically Fragile brochure

Reminder: Providers can book a ride for members!

Portrait of senior pediatric doctor and mother with baby in background

SoonerRide has long helped SoonerCare members get to and from their non-emergency health care appointments. But did you know that providers now have the ability to schedule transportation for our members as well? 

TripCare is a website that allows providers to schedule rides for SoonerCare members. The service is provided by LogistiCare, which also administers OHCA's SoonerRide program.

TripCare is at no cost to providers, but you will need an EDI form 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.

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New PA process how-to now online

The rollout continues of InterQual® evidence-based questions and answers into the medical prior authorization (PA) function of the SoonerCare Provider Portal. The transition to this new PA process, as first described in Provider Letter 2017-35, will take place during the next 10 months and will include most medical PA requests*.

To help providers prepare, OHCA has a tutorial available for download on our Training webpage. “Prior Authorizations with InterQual® Integration” walks you through what to expect, what is required, and how to complete the new PA request successfully. We encourage all medical providers to familiarize themselves with these instructions.

If you have any questions about this PA process change or the InterQual® implementation, please call the OHCA Provider Helpline at 800-522-0114.   


* As a reminder: Approved PAs are not a guarantee of payment due to a variety of reasons (such as eligibility, etc.).

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Behavioral health: Suicide prevention

Depressed man sitting alone in an illustrated storm


Two recent celebrity deaths have sparked a serious national dialogue about the tragedy of suicide. Suicide is the 10th leading cause of death in the United States and is a major public health concern. It does not discriminate - people of all genders, ages, socioeconomic status, and ethnicities can be at risk. Suicide is complicated and tragic, but it is often preventable.

Primary care is a key setting for suicide prevention. Up to 45 percent of individuals who die by suicide have visited their primary care physician (PCP) within a month of their death; additional research suggests that up to 67 percent of those who attempt suicide receive medical attention as a result.1

People at risk for suicide often feel more comfortable seeing their PCP since the provider may be the only access to health care they have - as such in rural areas - or they do not want to see a mental health professional for fear of stigmatization.

Physicians and other health professionals can work to identify persons at risk of suicide by recognizing warning signs and performing behavioral health screenings on all of their patients. Once a person is identified as at-risk, then appropriate interventions and referrals can be offered to help the patient. 

Suicide warning signs
Warning signs that a patient may be at risk of suicide:

  • Talking about suicide or death.
  • Withdrawing from friends and family.
  • Giving away money and cherished possessions.
  • Neglecting his or her appearance and hygiene.
  • Giving direct and indirect verbal cues such as “I wish I were dead,” “Soon you won’t have to worry about me,” or “Who cares if I’m dead anyway?”
  • Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn.

Behavioral health screenings
OHCA has put together a Behavioral Health Screening Toolkit to assist providers with screening their SoonerCare patients. Two of the items included in the toolkit are our very own pediatric and adult screeners that SoonerCare providers can utilize to screen for various mental health concerns and substance abuse. 

Additional screening tools
OHCA has also identified validated public domain screening tools that are available to assist physicians and behavioral health professionals with screening and assessing mental health issues. While we have provided this list, it is up to the provider to ensure they are utilizing the most current version. We also make no representation that this list is comprehensive.

Behavioral health referrals
To locate a SoonerCare-contracted behavioral health provider, please call 1-800-652-2010 or use the online SoonerCare Behavioral Health Provider Directory.

Suicide Prevention Lifeline logo

National Suicide Prevention Lifeline
If you, or someone you know needs help:

  • Call toll free at 1-800-273-TALK (8255), 24 hours a day, 7 days a week
  • Deaf and hard of hearing can contact Lifeline via TTY at 1-800-799-4889
  • Text “Talk” to 741741


  1. Reed, J. (2013). Primary Care: A Crucial Setting for Suicide Prevention. eSolutions. Retrieved from

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Asian baby with fingers to her mouth

OTC teething product warning

The U.S. Food and Drug Administration (FDA) has warned against using over-the-counter (OTC) oral drug products containing benzocaine for anyone younger than two years. These products are of questionable efficacy and carry an increased risk of methemoglobinemia (a blood disorder in which too little oxygen is delivered to your cells), which may be fatal.

These products are currently still commercially available with the new contraindication against using the product for teething and for use in infants and children younger than two years for any indication.

Parents and caregivers are encouraged to follow the American Academy of Pediatrics' recommendations to ease teething pain. The safety announcement follows a previous recall recommendation concerning elevated levels of belladonna (a poisonous plant) in homeopathic teething tablets.

Opioids restricted to a seven-day supply

In May, Oklahoma Senate Bill 1446 was signed into law and places a seven-day limit on initial opioid prescriptions.

While enforcement and other details of the law are currently pending, many pharmacies and providers are already implementing these limitations.

The Oklahoma Commission on Opioid Abuse has issued several recommendations to help curb the state's opioid epidemic. The most recent information on the Oklahoma opioid epidemic may be found in the opioid newsroom.

Latest OHCA response to the opioid crisis

In 2012, approximately 2,300 Oklahomans died from an unintentional injury and accounted for 1 in 16 deaths.1 Poisoning is one of the leading causes of these accidental deaths, which includes prescription drug overdoses.1 According to the Injury Prevention Service of the Oklahoma State Department of Health (OSDH), there were 510 prescription drug deaths in 2014. Of those, 426 involved an opioid.

In an ongoing effort to combat these grim statistics, OHCA Pharmacy Services is incorporating the use of the morphine milligram equivalent (MME). Morphine is considered the “gold standard” for the treatment of pain, and the MME provides a conversion factor for one opioid to another.

The Centers for Disease Control and Prevention (CDC) considers the Medicaid population to be a high-risk group for fatal opioid overdose and cautions against exceeding 50 MMEs per day. OHCA will review and monitor claims based on these guidelines for quality assurance and program integrity.

MMEs for Commonly prescribed drugs – OHCA
As of May 25, 2018

Table - OHCA's MMEs for Commonly prescribed drugs

50 MME of hydrocodone = 50 mg of hydrocodone
10 tablets of Norco® 5/325
6 tables of Norco® 7.5
5 tablets of Norco® 10


For more information, check out our new MME infographic.

The use of MME is the latest in OHCA’s commitment to combat the opioid epidemic.

Other opioid initiatives include the SoonerCare Pain Management Toolkit - a free resource for prescribers that also offers a practice facilitation component. The Patient Review and Restriction Lock-In Program aims to assist health care providers in monitoring potential abuse or inappropriate use of controlled prescription drugs by SoonerCare members. A third initiative, made possible through a Health Services Initiative – Children’s Health Insurance Program (CHIP) grant, enables the OHCA and the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) to provide free naloxone (overdose reversal) kits across the state. Lastly, in 2014, OHCA Pharmacy Services restricted the amount of short-acting opioid analgesics paid per claim to 120 units per 30-day supply.



  1. Oklahoma State Department of Health. (2014). 2014 State of the State’s Health. Retrieved from

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Waivers: Medically Fragile renewal

Closeup of young woman's hand holding older woman's frail hand  

On June 7, 2018, the OHCA was approved for a five-year renewal of the Medically Fragile Waiver. The waiver serves individuals 19 years of age and older who have a life-threatening condition, require frequent specialized treatment and have a dependency on medical technology.

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Electronic health records: Incentive Program updates

Eligible professionals (EPs) and hospitals (EHs) who have not participated in the Electronic Health Record (EHR) Incentive Program prior to 2016 are no longer able to participate in the program. 

Any EH participating in the program must attest in consecutive years. Hospitals are no longer able to skip a year.

Changes for Program Year 2018 are currently in process. We hope to make these updates July 31, 2018.  

Please note: For Program Year 2018, EPs and EHs may attest to a 90-day reporting period for Meaningful Use but are required to report on a full year for clinical quality measures, or CQMs. The only exception is for EPs in their first year of Meaningful Use. They cannot submit their 2018 attestation any earlier than Jan. 1, 2019.

If you have any questions or concerns regarding this program, please contact the EHR Incentive Team at or by phone at 405-522-7347. You can also visit us online at

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New on

Weigh in on Oklahoma’s Medicaid community engagement requirements

Beginning on or after Feb. 1, 2019, the state of Oklahoma will implement community engagement requirements for certain individuals related to SoonerCare (Oklahoma Medicaid) eligibility upon approval from the Centers for Medicare & Medicaid Services (CMS). As a condition of eligibility for benefits, applicants or existing members - not otherwise exempted - age 19-50 must provide verification of employment or community engagement in specified educational, job training or job search activities for at least 80 hours per month. This equates to approximately 6,000 current members who would be subject to these requirements. Members who fail to meet these requirements for three months during a plan year will be dis-enrolled from SoonerCare until requirements are met.


Certain individuals are exempted from the above requirements. Those individuals include, but are not limited to:

  • pregnant women
  • individuals with a disability
  • a parent caretaker responsible for the care of a dependent child under age 6
  • individuals enrolled in Insure Oklahoma
  • American Indians and Alaska Natives

This new eligibility criterion was directed by an executive order signed by Gov. Mary Fallin on March 5, 2018. Additionally, the state legislature passed House Bill (HB) 2932, which the governor also signed into law. HB 2932 mandated SoonerCare eligibility include criterion for work or job activities as required for the Supplemental Nutrition Assistance Program (SNAP).

Please visit the OHCA website for more information, including FAQs, timelines and other resources.

Public Comment and Input

The OHCA welcomes comments from the public regarding this amendment to the SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration Waiver program. The full application waiver is available for viewing on our website through Sept. 3, 2018.

Submit your comments and questions through the OHCA Policy Change Blog or by contacting the OHCA Federal & State Reporting Division by phone at 405-522-7914 or via email:

The OHCA also expects to conduct several public meetings around the state July-September. Please check the agency’s website for specific dates, times and locations.

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Help your patients quit tobacco

Female provider counsels African American woman about quitting tobacco


With the recent cigarette tax increase, health care providers are likely to see an influx of patients interested in quitting tobacco. They’ll have lots of questions and they’ll look to you for answers.

As a health care professional, you play a critical role in helping your patients quit. By offering information, options and support, you can help them reduce the impact tobacco has on their health.

Along with the cessation benefits available through SoonerCare, the Oklahoma Tobacco Helpline offers helpful tools and services for tobacco users and their health care providers. They provide 24/7 nonjudgmental support and their free services are customizable to help patients quit their own way. These services include text and email support, phone and web coaching, nicotine replacement therapies and more — all free.

Even if a patient is just thinking about quitting, the Helpline offers resources to educate them about the benefits. Here are some tools to start them on their path to living tobacco free.


This quiz helps patients assess their attitudes about tobacco and willingness to quit.


This handy calculator shows patients how much they’re spending on tobacco and how much they can save by quitting.


Order or download free fact sheets, stress management flyers, tip cards and more to share with your patients. Available in English and Spanish. 

No matter how long a patient has used tobacco, quitting leads to a longer, healthier life. People who quit smoking, dipping or chewing avoid health problems, save money and take control of their lives. And those who use a quit line like the Oklahoma Tobacco Helpline are four times more likely to stop smoking than those who go it alone.

To access resources for physicians and their patients, visit or call 1-800-QUIT NOW.

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OHCA Provider Helpline: 800-522-0114


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Checkup Statement

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

Appointment Reminders


July 11
Drug Utilization Review (DUR) Board Meeting

July 19
Medical Advisory Committee (MAC) Meeting

August 8
DUR Board Meeting

August 9
OHCA Board Meeting

View complete OHCA calendar here

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Dr. Garth Splinter named ‘Rural Health Leader of the Year’

Garth Splinter, M.D., MBA,

Garth Splinter, M.D., MBA, has received the “Rural Health Leader of the Year” award from the Rural Health Association of Oklahoma. The award was presented at the Annual Awards Luncheon during the Oklahoma Health Conference in Norman, Okla., on May 22.

Dr. Splinter, recently retired as deputy CEO of the Oklahoma Health Care Authority (OHCA). Formerly he served as state Medicaid director and also the agency’s first CEO.

According to the nomination criteria, the “Rural Health Leader of the Year” recipient “should be an outstanding rural health leader who uses a comprehensive or unique approach to address a specific rural health issue; demonstrates an ability to guide others through complicated rural health issues to achieve a set goal, and/or creates a network or partnership with others to create programs or initiatives that benefit rural Oklahomans.”

Becky Pasternik-Ikard, CEO of the OHCA, wrote in Dr. Splinter’s nomination: “… Dr. Splinter’s effort laid the foundation for SoonerCare’s present day partially capitated care management program … Dr. Splinter continued his efforts to enhance our rural provider networks. In state fiscal year 2017, OHCA provided coverage to more than one million Oklahomans of which 46 percent are categorized as living in rural areas …Our state has benefitted from his service and Oklahoma’s health care environment has been positively influenced by his efforts.”

For information about the Rural Health Association of Oklahoma, visit

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Seeking input from rural health providers

The Rural Healthcare Simulation Center is hoping to gauge your views with regard to the first national, independent and non-profit rural-oriented Praxis Simulation Training Center being developed in Butte, Montana. Please take five minutes to complete a very short user validation survey at:

The Center will support the training needs of health care physicians, nurses, technicians, EMTs and first responders throughout the U.S. and Canada. Scores of accredited CME and CEU courses will be offered both on-site and through distance learning – helping to fill the gaps faced by many rural health care organizations. Praxis will also focus on soft skills to address the workplace environment among rural practitioners. The Center will also include a mixed-reality, open simulation scenario room to help train first responders and military personnel.

Additional information may be found at

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