September 2024
Please update your Oklahoma Health Care Authority (OHCA) provider files to ensure all details, including new or missing locations and group member assignments, are accurate. If your update impacts services under SoonerSelect partners, email your application tracking number, received upon submitting your update on the OHCA provider portal, to providerenrollment@okhca.org with "SoonerSelect update" and your application tracking number in the subject line.
For the following provider types, 75-day renewals started July 17, and contracts expire Sept. 30, 2024.
- Physician
- SUD residential
- OP SUD
- OTP
- Halfway house
- Medically supervised withdrawal management
For the following provider types, 75-day renewals started Aug. 17, and contracts expire Oct. 31, 2024.
- Adult day services
- Agency companion services
- Architectural modifications
- Community transition services
- Daily living supports and intensive personal supports
- DDSD registered nurse
- Employment services
- Family counseling services business
- Family training
- Foster care
- Group home services
- Habilitation training specialist
- Home health skilled nursing services
- Homemaker services
- Respite service
- Transportation business/individual/public
Please be sure the contact information, including email address, is current for all individual and facility/group provider files so you can quickly receive important contract information.
In 2022, over 700 Oklahomans died due to an unintentional opioid overdose. According to the Centers for Disease Control and Prevention's opioid overdose dashboard, over 50% of the nearly 1,300 overdose deaths in Oklahoma from any drug involved at least one opioid, including those both legally and illegally obtained. Recent national data shows more than 40% of opioid overdose deaths were in the presence of a bystander, meaning lives could have been saved if people nearby had administered naloxone.
Knowing when to offer naloxone to patients is a critical first step. According to the CDC, currently only 1 naloxone prescription is dispensed for every 70 high-dose opioid prescriptions. Naloxone is covered by SoonerCare and does not count toward the member’s monthly prescription limit. Naloxone is also available for free by mail at OK I'm Ready. If you have questions about naloxone coverage, call the Pharmacy Help Desk associated with your patient’s health plan.
As a health care provider, you know that every life, and every story, is unique. You also know it's never too late to make a positive, healthy change. Your older patients who use tobacco may think it’s “too late” to quit, but your assurance and guidance can change their minds — and their lives.
It’s not just about adding years to life — it's about adding life to those years. Quitting smoking or tobacco can significantly improve your patients’ quality of life. Here’s how you can support patients of all ages on their quit journeys.
-
Emphasize the Benefits: Quitting tobacco can immediately lower patients’ risk of heart attack, stroke and lung disease. Food will taste better, smells will become stronger and energy levels will increase — giving them the stamina for family time and sweet memories.
-
Remind Them of Their “Why:” Encourage patients to reflect on their personal reasons for better health. It could be watching grandchildren grow up, enjoying hobbies discovered later in life or setting a strong example. Helping them connect to their motivation can be a powerful tool.
-
Offer Support: Quitting tobacco is hard. Let your patients know they’re not alone. Provide guidance, support, encouragement and advice as they embark on this new journey.
Your advice can make all the difference. The Oklahoma Tobacco Helpline offers free support to all Oklahomans thinking about quitting tobacco. Your patients will gain access to several services, such as encouraging coach call(s) and nicotine replacement therapy, like patches, gum or lozenges. Encourage them to check out the free services to find what works for them.
Looking for a way to start the conversation? Get free Helpline materials for your office, such as pens, brochures, badge reels and posters. Order your supplies at OKhelpline.com/order.
Always Check History
Even if a member is new to your office, it's always possible they've received treatment with a different provider. So please continue to check history before submitting prior authorization requests. The dental unit will return any request if the member has already received services. In addition, a prior authorization approval is not a guarantee of payment. The day the member is in the office, be sure to check member eligibility and treatment history before rendering services. The member is not liable for payment should this oversight occur.
Services Requiring Prior Authorization
The minimum required records you must submit with each dental prior authorization request are:
- A comprehensive treatment plan containing member's treatment history and clinical notes.
- Right and left mounted bitewing X-rays or a panoramic X-ray.
- Periapical films of tooth/teeth involved displaying 3mm beyond the apex of the tooth as stated in the policy.
X-rays and images must be identified by the tooth number and include the date of exposure, member name, member ID, provider name and provider ID. All X-rays and images, regardless of the media, must be submitted together with a completed and signed comprehensive treatment plan that details all needed treatment at the time of the examination. The film/print must also clearly identify the requested service. If you are requesting periodontal services, please send periodontal charting. Records will not be returned.
Charging Members
Providers may not charge members for follow-up care. Please see policy listed below and the provider's responsibility regarding follow-up care. Reports of providers charging for follow-up chare are referred to the OHCA Quality Unit for investigate.
When in doubt, call the dental unit for questions before billing a member for services or refusing to provide care until the member has paid.
-
Removable Prosthodontics: 317:30-5-698. Services requiring prior authorization. (1) Removable prosthetics. (A) This includes full and partial dentures. (i) One (1) per every five (5) years is available for adults under twenty-five (25) years of age. (ii) One (1) per every seven (7) years is available for adults twenty-five (25) years of age and over. (iii) Provider is responsible for any needed follow-up for a period of two (2) years post insertion.
-
Endodontics (iv) Providers are responsible for any follow-up treatment required by a failed endodontically treated tooth within twenty-four (24) months post completion.
-
Orthodontics 317:30-5-700.1. Orthodontic prior authorization (oklahoma.gov) (2) Claim and payment are made as follows: (A) Payment for comprehensive treatment includes the banding, wires, adjustments as well as all ancillary services, lost or broken bracket replacement, including the removal of appliances, and the construction and placing of retainers. Members are not to be charged for broken brackets.
Prior Authorization Submission
To expedite the initial review of prior authorizations, please ensure the authorization has been entered correctly. A claim submission must match the authorization. For example, quadrants listed on prosthodontic requests or relines will be canceled with code 252 and/or 385 as the quadrant should not be listed. Quadrants are required for periodontal requests.
Dental Page on the Public Website:
OHCA has a page devoted to dental services that contains links to policy, dental fee schedules, dental forms and other useful information, such as an amendment tutorial. By logging in to the provider portal, you can view items such as prior authorization status and access amendment submissions.
Did You Know?
You can view OHCA's global messages and subscribe to web alerts in order to view current and previous provider updates.
This summer, Mona contacted the Oklahoma ABLE Tech Device Reutilization Program after a referral from her physical therapist. Mona and her husband needed several types of durable medical equipment (DME) and medical supplies.
After submitting their application, Mona received a knee walker and her husband received a shower chair, bedside table, incontinence supplies and a wheelchair cushion.
Mona’s mobility was greatly increased with the assistance of the knee walker, which allowed her to continue caring for her husband! She said the DME her husband received has helped him maintain his dignity and remain as independent as possible.
To learn more about the Device Reutilization Program, how to apply to receive DME, or how to donate gently used DME, visit the Oklahoma ABLE Tech website.
|
Q: What are the requirements for equipment-related prior authorization (PA) requests for physical therapy and occupational therapy?
A: If a patient is being seen at a clinic for equipment needs and no other treatment is to be provided, then an evaluation or progress note is not necessary to be provided (as long as it is the CPT listed below being requested). In this case, the PA request needs to include the parental consent form, the equipment-specific referral from a qualified provider, a completed HCA 61 form, and a statement from the therapist of record stating that coverage is being sought purely to meet equipment needs.
Valid CPT codes for the above requests include 97542, 97535, 97755, 97760, 97761, and 97763.
If a patient is being seen at a clinic for an ongoing issue and there is a need for equipment, a line-item addition amendment will be required to be submitted on the existing PA. The amendment will need to include the HCA 60 amendment form, an up-to-date progress note with elaboration on progress per established goal, a parental consent form, and the equipment-specific referral.
Q: Who performs PA request reviews for the therapies?
A: Submissions for each of the three therapies (physical therapy, occupational therapy and speech therapy) are clinically reviewed by a professional in the respective field. The reviewer ensures that: the specific documentation is consistent with the profession’s standards of practice and code of ethics; tests and measures are appropriate for the patient presentation; goals meet established criteria and allow timely progress tracking; and the therapist’s assessment justifies the medical necessity for requested services to potentially improve the patient’s outcomes.
Q: How long after completion of the profession-specific note should a PA request for the therapies be submitted?
A: For PT/OT, an up-to-date progress note will be required if a period of greater than 30 days has been exceeded since the submitted note for clinical review was completed. The rendering clinic is responsible for timely submission of documentation for PA review and uninterrupted care delivery. OHCA will review and decide upon submissions within a business week. In most cases decisions are within 72 hours.
Though speech therapy (ST) does not have a set requirement on how long after completion of an evaluation or progress note a PA request should be submitted, it is important to keep in mind the ethics of uninterrupted care delivery.
Each of the three therapies is allowed one evaluation charge per member per year. For PT/OT, a reevaluation can only be billed if criteria are met at least 6 months from completion of the evaluation. For ST, a second evaluation can be performed after 6 months have passed in a change of provider situation. It is imperative that each profession plan and perform routine ongoing reassessments for effective progress tracking and provide an up-to-date summation of medical necessity when requesting new or continued authorization for services.
|
