OHCA Provider Newsletter • April 2024

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SoonerCare Provider Memo

April 2024

Included in This Edition

SoonerSelect Provider Resources

SoonerSelect health and Children's Specialty Program coverage has begun. Several resources are available on the OHCA SoonerSelect provider page to answer your questions.

The fact sheets include a checklist for providers in preparation for the coverage beginning. Reference guides include information on topics such as verifying member eligibility, prior authorizations, continuity of care, claims and more. All materials are available for download.


Spring Into Health with the Helpline

Spring Quit Now graphic

As the weather warms and the flowers bloom, there’s no better time for a fresh start. Now is the perfect time to encourage your patients to quit tobacco with the Oklahoma Tobacco Helpline.

With more than 590,000 registrations, the Helpline is ready to support every Oklahoman with free quit services including:

  • Nicotine Replacement Therapy
    Patches, gum or lozenges increase your patients’ odds of quit-success.
  • Coach Support
    Engaging sessions via phone, text and chat. Coaches provide quit strategies, tips and support in navigating the Helpline.
  • Live Online Group Sessions
    Coach-led meetings facilitate peer connections, coaching and advice.
  • Encouraging Texts and Emails 
    Timely tips for your patients when they need them most.

The Helpline has helped thousands of Oklahomans live tobacco-free lives. Your patients could be next.

Talk to Patients About the Diabetes Education Benefit

Photo of a health care worker checking a patient's glucose

More than 75% of SoonerCare members don't know that diabetes education is a covered benefit.
SoonerCare members may receive 10 hours of training during the first year. Each subsequent calendar year, members are eligible for two hours of individual or group instruction.

Providers seeking to provide Diabetes Self-Management Education and Support (DSMES) services must meet qualifications and complete the DSMES-specific enrollment process. This includes: 

  • Enroll in the specific DSMES program as a Diabetes Self-Management Group.
  • Enroll each specific provider as a diabetic educator and connect them to the DSMES program.

DSMES providers must complete the DSMES-specific process even if they are already an enrolled provider.

If you have additional provider enrollment questions, call 800-522-0114, option 5, or email ProviderEnrollment@okhca.org.

In addition to diabetes education, SoonerCare also covers continuous glucose monitors for qualifying members at the pharmacy point of sale. Some members may require a prior authorization. SoonerCare also covers 90-day fills of many diabetes maintenance medications. Given the recent increase in the use of diabetes (and similar) medications for weight loss, it is important to remember that medications for weight loss are currently not covered by SoonerCare.

Call the SoonerCare Pharmacy Help Desk at 405-522-6205, option 4, or 800-522-0114, option 4, if you have medication coverage or other pharmacy benefit questions.

Nutrition Counseling

Photo of fresh fruits

As health care professionals, you know that obesity is a chronic disease that can lead to cardiovascular and other health conditions. SoonerCare can assist your patients in achieving a healthier weight. Learn more about the medical nutrition therapy benefit, which includes six hours of nutritional counseling per year for members. Refer your patients today!

The Link Between Smoking and Colorectal Cancer

Photo of male patient with health care worker

On the heels of Colorectal Cancer Awareness Month comes an opportunity to raise awareness about the health impacts of smoking. The link between smoking and colorectal cancer may not be as apparent, but the cancer-causing toxins can lead to large and harmful polyps in the colon.

Heavy smokers increase their risk of developing colorectal cancer by 61%.

Remind your patients that regardless of how long they’ve been smoking, quitting now can significantly reduce their cancer risk and improve overall health. SoonerCare supports our member’s journeys to quit by covering provider tobacco cessation counseling and covers all seven FDA-approved nicotine replacement therapies. 

If you have patients who have or are at risk of colorectal cancer, encouraging them to quit smoking can be a life-changing conversation. Need help getting started? Order free materials for your office to educate your patients on the Helpline’s benefits and encourage them toward tobacco-free lives. For more information, visit the SoonerQuit for providers page.

Volunteers Needed for Research Study

The University of Oklahoma Health Sciences is conducting a research study entitled "Doulas and Maternity Care Teams: Strategies for Collaboration and Integration." It's intended to learn more about the knowledge, attitudes, and practices among maternity care providers regarding birth doulas. It also seeks to assess the feasibility of doula programs by researching current practices.

All physicians, physician assistants, nurse practitioners, labor and delivery nurses, and administrators working in maternity care are invited to participate. Please complete the survey by Friday, April 12.

If you choose to participate, your consent is implied by completing the survey. You will not be identifiable by name or description in any reports or publications about this study. Respondents will be entered into a drawing to receive one of 20 gift cards at $25.

If you have any questions, you can contact the doctoral student researcher, Angela Helt, MA, at angela-helt@ouhsc.edu, or the Principal Investigator, Kerstin M. Reinschmidt, PhD, MPH, at kerstin-reinschmidt@ouhsc.edu.

The University of Oklahoma is an equal-opportunity institution.

Therapy FAQs

Photo of a man in physical therapy


Can I start seeing my patient without an approved Prior Authorization Request (PAR) expecting a TEFRA award letter?

To ensure coverage is guaranteed, a clinic must wait for an authorization approval before initiating care. The service-rendering clinic is responsible for submitting a PAR within 30 days of the date on the award letter for services to be covered. Failure to submit the PAR along with all the required documentation within 30 days of the date on the award letter will result in no coverage.


When is a progress note required, and what must it include?

Progress notes should occur at least every 30 days. They are the minimum form of documentation required to ensure a standard system of progress tracking to ascertain ongoing medical necessity. Progress notes are required for ANY subsequent authorization requests, change of provider requests, unit change amendments, date change amendments, line-item addition amendments, code change amendments, TEFRA submission, and if more than 30 days have gone by since a prior evaluation or previous progress note was completed.

Here are a few key things that a progress note must include:

  • Subjective remeasurements (goal specific)
  • Objective remeasurements (goal specific)
  • Therapist assessment with justification of medical necessity
  • Addressing of attendance
  • A titration/discharge plan
  • Absolute goal progress

The absolute goal progress must include a commentary for each listed goal with the patient’s current level of achievement toward the goal tied to subjective and objective remeasurements. A met goal can simply state “met,” and a newly added goal can state “baseline.” Please revisit the December 2023 newsletter regarding the criteria for the goals.

Here is an example from the goal from the December 2023 newsletter in a progress note submission for a subsequent authorization request (assume the initial authorization was approved for a 6-month period):

Dar will elicit ability to perform the single leg hop test for at least 75cm for the R. LE by 6 months without compensatory movement patterns, suggesting good synergistic LE muscle activation for a safe return to age-appropriate activities and participation in high school basketball.

(Current progress: in progress per remeasurements – patient demonstrated ability to initiate SL hop safely at 5 months post-op today at almost 6 months post-op, he can control 55cm and can perform 65cm with mild upper body swaying present eliciting continued need to improve synergistic LE stabilization when landing; Prognosis: excellent with continued coverage for up to 2 more months.)



When can I be reimbursed for a re-evaluation instead of doing a progress note?

Re-evaluations will only be reimbursed when the patient documentation supports that the change in status or condition requires additional evaluative service.

  • A newly diagnosed but related condition: In the above example, if 8 months are approaching in the subsequent authorization and Dar has progressed well, but as a result of the plyometric emphasis, is now having new pain in the anterior knee region inferior to the patella – this would be a reason to re-evaluate. Note that initial evaluations can be performed 12 months apart or more.
  • Patient is demonstrating a significant improvement, decline or change in condition or functional status that was not anticipated per the plan of care, necessitating additional evaluation to maximize rehabilitation potential. In the above example, if Dar showed an ability to control the SL hop with a 45-pound barbell for 80 centimeters at 6 months, a re-evaluation can be performed as this is significant improvement that may require modification to the POC to maximize his potential before returning to high school basketball. But if, at 6 months, Dar is showing decreased ability to bear weight, difficulty walking and a decrease in strength, this would be a significant decline in functional status that was not expected per the POC and would necessitate a re-evaluation to maximize rehabilitation potential.
  • Re-evaluation can be reimbursed at 6 months or greater following the date of an initial evaluation and meeting the above criteria. Routine progress notes are an expected component of care.

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