OHCA legislative update and undeliverable mail rule changes

Provider trainings, important pharmacy alerts, tobacco cessation resources and new OHCA board members

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Summer 2019

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Legislative Update

2019 Legislative Summary

The first regular session of the 57th Legislature adjourned May 23, 2019.

SB1044 - Provider Rate Increase

  • 5% increase in the current reimbursement rates for SoonerCare-contracted long-term care facilities
State budget issues continue to impact operations at the Oklahoma Health Care Authority
  • 5% provider increase with some exclusions: services financed through appropriations to other state agencies, Durable Medical Equipment Prosthetics, Orthotics and Supplies, non-emergency transportation, services provided to Insure Oklahoma members, payments for drug ingredients/physician supplied drugs, Indian Health Services/Indian Tribal/Urban Clinics and Federally Qualified Health Centers, Program for the All-inclusive Care for the Elderly and rural health centers.

HB2767 - Rate Preservation Fund

  • Creates a fund for the sole purpose of maintaining reimbursement rates to providers when decreases in FMAP would otherwise result in reimbursement rate decreases.

SB575 - Telemedicine in Schools

  • Requires parental consent good for one year

Expected interim discussions

  • Out-of-State Expenditures
  • Comprehensive Healthcare Reform from Governor Stitt
  • Psychiatric Resident Treatment Facility Audit
  • Treatment options for adults with Traumatic Brain Injuries (TBI)

The second regular session of the 57th Legislature is set to begin on Feb. 3, 2020.

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Provider Notes

Provider Services

Current Mailing Address REQUIRED Webinar

Smiling doctor and nurses standing outside a hospital

OHCA and DXC will be presenting a webinar titled Current Mailing Address REQUIRED on Thursday, July 25 and August 8. Each of the webinars will begin at 2 p.m. This webinar is applicable to all SoonerCare providers.

These webinars will cover information concerning amended and new OHCA rules that require SoonerCare members to keep their addresses up to date in order to have continued SoonerCare eligibility. It will highlight outreach efforts that OHCA will be making to members whose mail has been returned to OHCA and how providers can assist in these efforts.

Register to attend one of the Current Mailing Address REQUIRED webinars: https://okhca.org/xwebinars.aspx.

SoonerCare Out-of-State Services Rule Changes

Beginning Sept. 1, 2019 the Oklahoma Health Care Authority (OHCA) will enact changes to the agency’s out-of-state (OOS) services policies. These changes will continue to ensure members have access to quality care while controlling program costs. They will not impact routine medical care for SoonerCare members.

In 2019 the Oklahoma legislature passed HB 2341, which limited SoonerCare members’ services to in-state providers when possible. These changes to OOS services will allow OHCA to maintain compliance with federal and state regulations.

These revisions clearly define coverage and reimbursement for services rendered by providers that are physically located outside of Oklahoma. Also outlined are provider participation requirements, prior authorizations and medical records requests.

Click Here to view more information about the out-of-state services rule changes.


PRAMS Survey

PRAMS (Pregnancy Risk Assessment Monitoring System) is an ongoing, population-based surveillance system that collects statewide data on maternal attitudes, behaviors and experiences before, during, and shortly after pregnancy.

  • Oklahoma has been a PRAMS state since the very beginning of the CDC project more than 30 years ago.
  • The survey is sent monthly to a stratified sample of between 200 and 250 mothers delivering a live birth.
  • Surveys are available in both English and Spanish and can also be done over the phone.

Providers can help by letting pregnant women know that, if chosen to participate, they will get this survey in the mail or get a phone call from the PRAMS project shortly after delivery. Their answers are confidential and important! The project’s sample design and size, methodology, historical response rates, and longevity make it a unique and reliable source of information on the health of mothers and babies in Oklahoma. Visit the Oklahoma PRAMS website (http://PRAMS.health.ok.gov) to learn more or to access online reports, publications or request custom data sets.

HIE Survey

The State of Oklahoma is planning to release an open, deliverables-based request for proposal (RFP) for a single statewide health information exchange (HIE). The state will be seeking a vendor to manage the operations and technology to support the statewide exchange of clinical health care information and other services to support the improvement in health outcomes.

We are seeking your input into the values, functionality and services of the statewide HIE. The survey opened on July 8 and will be open for two weeks. Once closed, the results will be evaluated and released via state agency websites. 

Your response to this survey will aid the state in prioritizing the deliverables and in identifying the values that should be achieved as a result of this investment. The survey can be accessed by clicking this link.

Provider Contracts

FQHC Contracts Term and Renewal Dates

Federally Qualified Health Center (FQHC) provider contracts expire Sept. 30. Renewals of these contracts may being July 17.

Click here to view the Federal Register requiring any applicable ACA screening fees. Please visit the Provider Enrollment webpage, under Contract Types, to view renewal dates.

If you have any questions, please contact Provider Enrollment at 1-800-522-0144, option 5.

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Patient Centered Medical Home (PCMH) Providers May Be Reimbursed for Fluoride Varnish Services

Patient Centered Medical Home (PCMH) providers may be reimbursed for fluoride varnish services.

317:30-3-65.8. Dental Services [Revised 10/1/2018]:
Separate payment will be made to the member's primary care provider for the application of fluoride varnish during the course of a child-health screening for members ages six (6) months to sixty (60) months. Reimbursement is limited to two applications per year by eligible providers who have attended an OHCA-approved training course related to the application of fluoride varnish. Click Here for more information and to view the approved courses.

Resin-Based Composite for Children

Effective May 20, dental services for children includes coverage of CDT code D2394, resin-based composite - four or more surfaces, for permanent teeth.

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New Opioid Limit Reminder

On Jan. 7, a new daily opioid Morphine Milligram Equivalent (MME) limit for SoonerCare pharmacy claims went into effect. This includes both short-acting and long-acting opioid formulations.

The edit will progress in three (3) phases, with the final phase occurring July 22 at 100 MME. MME daily totals over 100 MME will require prior authorization (PA) with patient-specific, clinically significant reasoning why the member requires more than 100 MME per day.* The end goal is 90 MME by Dec. 2019.


Providers can also access a patient’s MME totals by consulting the Oklahoma Prescription Monitoring Program (PMP) Aware system. OHCA encourages providers to access the PMP site and begin tapering (where appropriate) members who exceed the 100 MME threshold.

If a member requires daily MME totals exceeding 100, the provider can submit an MME override request via form PHARM-111, available on the OHCA Pharmacy Forms webpage (okhca.org/rxforms).

If you have questions regarding this quantity edit, you can reach Pharmacy Services via the OHCA Provider Helpline at 800-522-0114, option 4.

*Medications provided for Medication-Assisted Treatment (MAT) will be exempt from this policy.

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PA Lifted on MAT Products and DEAX Number Reminder

Effective July 31, 2019 prior authorization for Medication-Assisted Treatment (MAT) is no longer required on preferred products. Providers must have a DEAX number on file with OHCA. To ensure that your number is on file, please email your DEAX number to providerenrollment@okhca.org. Download specific prior authorization criteria at okhca.org/MAT

No Prior Authorization Required
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Tobacco Cessation


The Key to a Tobacco-Free Summer

Summer has arrived in Oklahoma, and with it brings lake trips, block parties and family gatherings. It is an exciting time for many of your patients, and it is the right time for them to think about quitting tobacco.

Talk to your patients about how quitting can impact their overall health, decreasing their risks of mouth and throat cancer, heart disease and type 2 diabetes. Plus, FREE services, resources and support are available from the Oklahoma Tobacco Helpline.

Encourage your patients to call 1-800-QUIT NOW or visit OKhelpline.com. Oklahomans over the age of 13 are eligible to register for the Helpline. With just one call or click, your patients can enjoy 24/7 nonjudgmental support and customizable plans to quit tobacco the way that works for them. Registrants can also receive text and email support, coaching calls and web coaching. Plus, your patients over 18 can receive up to two weeks of nicotine replacement therapy: patches, gum or lozenges. SoonerCare members can also qualify for additional cessation benefits.

To make sure your patients are well-informed as they start their tobacco-free journeys, we have many health care provider resources, too! Visit OKhelpline.com to order free posters, fact sheets, brochures and more for your office.

Make this their sweetest summer yet. Learn more and order or download materials at OKhelpline.com.

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OHCA Changes Member Outreach Related to Undeliverable Mail

A rule being implemented by the Oklahoma Health Care Authority (OHCA) reminds SoonerCare (Oklahoma Medicaid) members to keep their home addresses up-to-date with the agency. Members who fail to do so risk losing their SoonerCare eligibility after outreach efforts are made by the agency to locate a current address.

The agency’s board approved the rule at their May 21 board meeting and it was signed by Governor Kevin Stitt on June 28. The rule will bring the agency into compliance with guidance from its federal partner, the Centers for Medicare & Medicaid Services (CMS).

Aside from the agency’s outreach efforts through social media and provider education, notice will also be posted to the member’s online SoonerCare account. Beginning this month the agency will begin an out-bound calling campaign after hours and on weekends to speak to members and update their address.

The agency is also educating providers, advocates, other state agencies and partners about the importance of an updated address and asking them to encourage members to update their address with SoonerCare.

Residing in Oklahoma is one of the eligibility criteria to qualify for SoonerCare. Returned mail indicates a potential change in circumstance with respect to residency. Therefore, if a member’s whereabouts are unknown and OHCA has made reasonable attempts to verify the member’s current address, OHCA will send a 30 day notice of discontinued eligibility to impacted members by mail and by email, if the agency has an email address on file.

Please direct SoonerCare patients with questions about these changes to the SoonerCare Helpline at 800-987-7767 or to their member portal at www.mysoonercare.org.

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2019 Permanent Rules

Rules and regulations

The 2018-2019 permanent rulemaking session came to an end in April. All of the Oklahoma Health Care Authority's proposed rules were approved by the Legislature and Governor through HJR 1022. All of the agency's permanent rules will become effective on Sept. 1.

Some of the permanent rules approved during the 2018-2019 permanent rulemaking session include, but are not limited to:

  • Lab Services Policy Revisions (APA WF# 18-01)  
    The revisions strengthen the language delineating medical necessity and compensable and non-compensable lab services. Additional revisions clarify that the Oklahoma Health Care Authority (OHCA) does not pay for all lab services listed in the Centers for Medicare and Medicaid Services (CMS) fee schedule, but only those that are medically necessary in addition to the four other conditions required for payment.
  • Inpatient Psychiatric Services Revisions (APA WF# 18-06) 
    The revisions clarify a prior authorization requirement for inpatient psychiatric services for adults. The revisions also align the time requirement of the first individual treatment by the physician to be within the sixty (60) hour requirement of completion of the psychiatric evaluation for Acute and Psychiatric Residential Treatment Facilities (PRTFs) settings.
  • Prepayment Review and Suspended Claims Review (APA WF# 18-09) 
    The revisions establish a new section addressing suspended claims review and/or prepayment review. This policy aligns the agency with state and federal laws that require the OHCA to safeguard against unnecessary utilization of medical supplies and services. Additionally, the revisions ensure that payments are consistent, efficient, economical, and provide good quality of care. These revisions also ensure that reimbursements are for medically necessary, correctly and/or appropriately billed, medical supplies and services. The changes define and explain the various reviews that may be performed by the OHCA or its contractor before the OHCA pays a claim.
  • Electronic Health Records Incentives (APA WF# 18-10) 
    The revisions outline how to qualify for the Electronic Health Records (EHR) Incentive Program by changing the timeframe in which hospitals must meet SoonerCare patient volume criteria for a continuous 90-day period from the preceding calendar year to the preceding federal fiscal year. Additionally, a 30-day time limit for eligible providers to submit documentation or make corrections to avoid denial of their EHR attestation has been added.
  • Provider Screening and Application Fees (APA WF# 18-13) 
    The revisions establish application fees required by federal law for providers enrolling or re-enrolling in Medicaid. The revisions define providers who are exempted from the application fee as individual physician or non-physician practitioners; providers who enrolled with and paid the fee to Medicare; and providers who enrolled with and paid the fee to another state Medicaid agency. Additional revisions outline provider screening and enrollment requirements designed to help defend against Medicaid provider fraud, waste, and/or abuse. Provider screening requirements are outlined according to three categorical screening levels: limited-risk, moderate-risk, and high-risk. Examples of screening requirements are licensure verification, on-site visits, and fingerprint-based background checks.
  • Appeals Timeframe Revisions (APA WF# 18-15 A, B, and C) 
    The revisions change all of the agency's appeals rules to extend the length of time that appeals can be submitted from twenty (20) days to thirty (30) days of the date of an adverse agency action.
  • Maternal Depression Screening (APA WF# 18-17) 
    The revisions add coverage and reimbursement language for maternal depression screenings at Early and Periodic Screening, Diagnostic and Treatment (EPSDT) well-child visits. Providers will be reimbursed for conducting a maternal depression screening at the child's well-child visit. The policy revisions also reiterate how the Oklahoma Health Care Authority adopts and utilizes the American Academy of Pediatrics' Bright Futures periodicity schedule including for the maternal depression screenings.
  • Psychiatric Services in Nursing Facilities Revisions (APA WF# 18-23) 
    The revisions clarify that when rendering a direct physician service visit in a nursing facility, a psychiatrist or a physician with appropriate behavioral health training is required to perform such service. Additionally, revisions clarify that other than the two (2) allowable direct physician services visit in a nursing facility, reimbursement for psychiatric services to members residing in a nursing facility is not allowed.
  • Out of State Services Process Development (APA WF# 18-24) 
    The revisions define and clarify coverage and reimbursement for services rendered by providers that are physically located outside of Oklahoma. Policy revisions also delineate out-of-state services, provider participation requirements, prior authorizations, and documentation/medical records requirements; and outline reimbursement criteria for out-of-state providers who do not accept the payment rate established through the State Plan.
  • Updates to Medicare Crossover Policy (APA WF# 18-27) 
    The revisions streamline crossover payments of Medicare/Medicaid dual eligible individuals for Part A and B services.
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services in Inpatient Psychiatric Settings (APA WF# 18-28) 
    The revisions comply with federal regulations by assuring that members under twenty-one (21) years of age, who are residing in qualified inpatient psychiatric settings, have access to a full range of medically necessary Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Revisions also emphasize that EPSDT services are accessible, regardless of whether such services are listed on the member's individual plan of care.
  • Federally Qualified Health Centers (FQHC) Encounter Limitations (APA WF# 18-30)The revisions reinstate administrative rules to allow and better define multiple encounters at Federally Qualified Health Centers (FQHCs). Additional revisions establish guidelines for these multiple encounters.
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Agency Updates

OHCA Names Defender of Health Award Winner

Defender Award

Chairman Hupfeld (left) presents Tony Armstrong with the 2019 Brickner Award.

The Oklahoma Health Care Authority (OHCA) has named former OHCA board chairman Tony Armstrong as recipient of the 2019 Dr. T.J. Brickner Defender of Health Award.

A resident of Broken Arrow, Armstrong was appointed to the OHCA board in 2007 by the Senate Pro Tem and served until 2019. He served as board chairman for the last year and a half of his tenure. Prior to his appointment to the OHCA board, Armstrong retired in June 2006 as the president and chief executive officer of Muskogee Regional Medical Center. He also served as president and CEO of Bay Health in Bay City, Mich., where he also was an executive with Bay Medical Center, and as president of the Hospital Council of East Central Michigan.

OHCA Board Chairman Stan Hupfeld presented the award during the agency’s June board meeting.

“Tony Armstrong has worked tirelessly to improve the health of Oklahomans served by SoonerCare,” said Hupfeld. “He has been a strong advocate of the agency’s mission and brought a wealth of experience to our board.”

The OHCA presented the first Brickner Award in 2005 to its namesake, a founding member of the OHCA board. The award was created by the agency to recognize some of the best examples of dedication and personal commitment to the low income, uninsured and underinsured residents of Oklahoma. The recognition celebrates the achievements of an individual or individuals, who work tirelessly in the service of other people, either in health care or a related field.

“We appreciate Tony’s years of public service to this agency by serving on the OHCA board. His steadfast support and commitment to the agency and the Oklahomans we serve are greatly appreciated,” said CEO Becky Pasternik-Ikard

Armstrong joins a notable group of people who have been recognized with the Brickner award including former OHCA CEO Dr. Garth Splinter, Charles “Ed” McFall, Dr. Steven Crawford, Mike Dover, Anne Roberts, former Senator George Miller, former State Representatives Dr. Doug Cox and Calvin Anthony.


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Provider Resources

Web Alerts

Online Training


Order Publications

Statistics and Data

Newsletter Archive

Welcome New OHCA Board Members

Randy Curry

Weatherford, OK
Appointed by Speaker President Pro Tempore

Robert Boyd

Owasso, OK
Appointed by Speaker President Pro Tempore

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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 www.okhca.org for the most up-to-date information.


Appointment Reminders


July 18
Medical Advisory Committee Meeting

August 9
Long Term Care Services Supports Advisory Committee Meeting

August 14
Drug Utilization Review Board Meeting

August 21
OHCA Board Meeting

September 11
Drug Utilization Review Board Meeting

September 13
Long Term Care Services Supports Advisory Committee Meeting

*All meetings take place at OHCA offices (4345 N. Lincoln Blvd., Oklahoma City), in the Ed McFall Boardroom, unless otherwise noted.

View complete OHCA calendar here