OHCA Provider Newsletter • February 2025

Oklahoma Health Care Authority sent this bulletin at 02/10/2025 11:30 AM CST

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SoonerCare Provider Memo

February 2025

Included in This Edition

Provider Files and Renewals

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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.

OHCA has extended the expiration date of physicians from Jan. 31, 2025, to Feb. 28, 2025. This will allow provider enrollment time to process incoming renewals without interruption of services to members. There are currently more than 12,000 physicians who have yet to renew their Oklahoma Medicaid contract. To avoid any delay in reimbursement, physicians are encouraged to submit renewals as soon as possible. You can log into the provider portal to complete your renewal. If you need assistance logging into the provider portal, please contact our internet helpdesk at 800-522-0114, option 2, option 1. Or email SoonerCareInternetHelpdesk@gainwelltechnologies.com.

For the following provider types, 75-day renewals started Jan. 15, and contracts expire March 31, 2025.

  • Hospital
  • ITU contracts
  • Optician
  • Optometrist

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.

March is Cancer Prevention and Early Detection Month

Photo of a doctor looking at a lung X-ray


Lung cancer remains the leading cause of cancer-related deaths, but early detection can significantly improve survival rates. As a SoonerCare provider, you play a vital role in connecting at-risk patients to lifesaving low-dose lung cancer screening (LDLCS).

LDLCS Eligibility Criteria

  • Ages 50-80.
  • Current smoker or quit within the past 15 years.
  • 20 pack-year smoking history.
  • No symptoms or history of lung cancer.

Why It Matters

Early detection increases survival rates to 90% for stage I cases. Despite its benefits, Oklahoma ranks low in lung cancer screening rates. Together, we can change that.

Let’s Make a Difference

March is Cancer Prevention Month and there's no better time to help your patients take proactive steps toward better health. For resources or support with LDLCS implementation, contact SoonerQuit@okhca.org or Marie.Bagwell@okhca.org.

Stress Awareness Support for Healthier Patients

Photo of a young woman eating a salad and smiling


Stress can significantly impact your patients’ overall health and exacerbate chronic conditions like diabetes, obesity and hypertension. As a SoonerCare provider, you can connect your patients to two key resources: Medical Nutrition Therapy (MNT) and Diabetes Self-Management Education and Support (DSMES).

With MNT, patients can:

  • Learn how nutrition supports stress reduction and overall health.
  • Manage chronic conditions aggravated by stress.
  • Develop practical meal-planning strategies to ease daily pressures.

SoonerCare Coverage: Eligible members can access up to six hours of free nutritional counseling per year with a licensed registered dietitian, available in person or via telehealth.

With DSMES, patients can:

  • Gain skills to manage diabetes and improve their quality of life.
  • Learn how to monitor and control blood sugar levels.
  • Get tools for managing stress, physical activity, and medications.
  • Reduce risks of complications.

SoonerCare Coverage: Eligible members with DM1 or DM2 qualify for one hour of individual instruction, nine hours of group education in the first year, and two hours of follow-up annually with an accredited DSMES program and certified diabetes educator.

Encourage Your Patients to Act

With Stress Awareness Month right around the corner in March, let’s work together to empower patients to take control of their health. Refer patients who qualify for MNT or DSMES today and help them create a plan for better nutrition and reduced stress. For more resources or support, contact the SoonerQuit team at SoonerQuit@okhca.org or Cameasha.Alao@okhca.org.

Creating Healthier Spaces for Patients, Employees and Visitors

Breathe Easy graphic

 

A tobacco-free workplace environment promotes the health and safety of everyone in your clinic by reducing exposure to secondhand and thirdhand smoke, encouraging tobacco cessation, and preventing the initiation of tobacco use.

To assist you, the SoonerQuit team has launched a comprehensive Tobacco-Free Environment Initiative that offers:

  • Educational Resources: Access to evidence-based materials for staff and patients.
  • Policy Support: Tools for drafting and implementing a “Gold Standard” tobacco-free workplace policy.
  • Signage and Recognition: Free “Breathe Easy” signage and resources to promote your clinic’s policy.
  • Training and Technical Assistance: Guidance on integrating tobacco cessation best practices, such as the 5A’s counseling method and nicotine replacement therapy.

Why Adopt a Tobacco-Free Policy?

  • Health Impact: Shield individuals from secondhand and thirdhand smoke and motivate staff and patients toward cessation.
  • Patient-Centered Care: Empower patients with resources like the Oklahoma Tobacco Helpline and FDA-approved cessation medications.
  • Operational Efficiency: Seamlessly integrate this policy with minimal disruption.

Let’s Work Together

SoonerQuit coordinators are available to help you create a healthier, tobacco-free clinic environment. We’re committed to making this transition seamless. Email us today at soonerquit@okhca.org or Cameasha.alao@okhca.org to learn more about the initiative or to request assistance with implementing a tobacco-free workplace policy.

Hepatitis C Virus (HCV) Treatment Coverage

Photo of a doctor explaining a prescription to a patient

 
Mavyret® (glecaprevir/pibrentasvir) is currently SoonerCare’s only preferred direct-acting antiviral (DAA) medication for treatment of HCV. It is available without prior authorization (PA) as part of an ongoing initiative by OHCA to cure HCV in the SoonerCare population.

For other DAAs, the PA criteria is still in effect and PA forms are still required. Additionally, PA requests for other DAAs require a patient-specific, clinically significant reason why the member cannot use Mavyret. The specific PA requirements are located on the OHCA website at www.oklahoma.gov/ohca/pa in the “Hepatic Disorders” therapeutic category. Initial PA requests for all other DAAs besides Mavyret must be submitted using all 3 HCV PA forms:

  1. The medication-specific PA form (e.g., Harvoni®, Pharm-33)
  2. Hepatitis C Therapy Intent to Treat Contract form (i.e., Pharm-28)
  3. Hepatitis C Therapy Pharmacy Agreement form (i.e., Pharm-29)

Continuation requests (for each refill) must be submitted using the Hepatitis C Therapy Continuation form (i.e., Pharm-30).

Prescribers are encouraged to follow current guidelines and Mavyret prescribing information when initiating testing for HCV, selecting an appropriate treatment regimen, and performing all necessary monitoring. Prior to initiating therapy for HCV, prescribers are encouraged to verify the member's SoonerCare/SoonerSelect eligibility is in effect long enough to complete treatment. All patients receiving HCV treatment should be monitored for compliance and counseled regarding the importance of compliance and finishing treatment.

Pharmacy Questions

For questions about pharmacy benefits for members covered by SoonerCare, please contact the SoonerCare Pharmacy Help Desk at (405) 522-6205, option 4, or toll-free at (800) 522-0114, option 4.

For questions about pharmacy benefits for members covered by SoonerSelect, please contact the pharmacy help desk associated with your member’s health plan or email SoonerSelect@okhca.org.

Therapy FAQs

Photo of a speech therapist with a patient

 

What is required in my PT/OT PA submission?

Depending on the period of the request (initial vs. subsequent/continuation), documentation requirements may change. Additionally, situations such as a transfer-back (returning to OHCA from Sooner Select), change of provider (services to be delivered under a different Provider ID), equipment needs (services for equipment-related needs only), TEFRA (retroactive eligibility), or amendments involve their own specific requirements. Regardless of the situation, implementing routine reassessments as a component of ongoing care will help in justifying medical necessity for coverable services at any given moment. Please feel free to print out and use the table below as a guide when submitting a PA request on the PA portal. Please refer to the previous month’s publication for SLP requirements.

Submission Type Documentation Requirements Limitations

PT/OT Evaluation
CPT: 97161, 97162, 97163,
97165, 97166, 97168

 

 

1. A PA is not required for an evaluation. Each member is entitled one evaluation charge per year.

1. Treatment PA request needs to be submitted within 30 days of completing the evaluation to avoid the need for a progress note.

PT/OT Treatment Request CPT: 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97164/97168, 97530, 97535, 97602, 97022, 97532, 92526 

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Evaluation note - if initial request.

4. Progress note – if request is to continue services within the year of above evaluation.

5. Rx for services or SC-10 Referral Form.


6. Above requirements apply for the re-evaluation CPT codes as well.

 

2. Request cannot exceed one year from parental consent.

3-4. One of these is necessary, and the request needs to be submitted to start within 30 days of completion of either note to avoid the need for another up-to-date note.

5. Request cannot exceed one year from the signed date on the Rx.

6. Re-evaluation CPT code can be used when there is a significant change in status requiring additional evaluative services. This code can be listed as a line-item along with other treatment CPT codes and can be claimed once at least 6 months after the
evaluation.

PT/OT Equipment-Related Request
CPT: 97542, 97535, 97755,
97760, 97761, 97763

 

 

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Rx for equipment-specific services.


4. Statement from therapist of record.

 

 

5. If any CPT codes from the treatment request are present, refer to the box above.



2. Request cannot exceed one year from parental consent.

3. Request cannot exceed one year from the signed date on the Rx.

4. Statement needs to elaborate that services are being sought to meet equipment needs only (listed CPT codes).

5. If treatment is being provided beyond what is needed for equipment needs, then apply the requirements/limitations from the box above.

PT/OT Transfer-Back Request

 

 

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Rx for services.

4. SoonerSelect CE approval letter.

 

 


5. Evaluation note - submitted to the SoonerSelect CE for initial authorization.

6. Progress note – showing patient’s status during the transfer period.

1-4. All transfer-back PA requests will be approved, upon meeting documentation requirements, for a period of up to 90 days or the original end-date of the SoonerSelect CE approval letter, whichever period is shorter. The end-date will also be reduced based on the year timeline of parental consent form and Rx for services.

5-6. An evaluative or progress note completed 30 days before the transfer-back, or a progress note completed any time after the transfer-back date will be necessary.

PT/OT Change of Provider Request

1. HCA-61 form.

2. SC-15 Parental Consent form or clinic’s own equivalent.

3. Evaluation note or progress note from the previous clinic.

4. Current progress note from the new clinic.







5. Rx for services.


6. SC-16 Change of Provider form.

 

2. Request cannot exceed one year from parental consent.

3-4. An evaluative or progress note completed within the past 30 days is necessary. This note can be from the previous clinic (per appropriate handoff) or new clinic if continuing care under the established POC after the length of time. The new clinic can perform a new evaluation being mindful of the yearly reimbursement.

5. Request cannot exceed one year from Rx.

6. New clinic is responsible to ensure that the family has communicated this provider change with the previous clinic. If not, please ensure that the previous clinic is aware that care is to now continue at your location.

PT/OT TEFRA Request

 

1. HCA-61 form.

 

 

2. SC-15 Parental Consent form (if available).


3. Evaluation note or progress note completed prior to the historic start date.


4. Rx for services.


5. TEFRA award letter granting retroactive eligibility.

 

6. A current progress note.

1. Needs to reflect the historic start date and the future end date and account for the entirety of services.

2. If available, consent form does not need to be an OHCA- specific.

3. The evaluation or progress note that was performed up to 30 days before the historic start.

4. Rx needs to be signed/dated before the historic start date.

5. Submission should occur timely once the family provides the clinic with a copy of this letter.

6. A current progress note from the past 30 days is necessary if services are to not only be retroactive but also seek coverage for the future.

PT/OT Amendments

1. HCA-60 Amendment form.




2. A current progress note from the past 30 days will be necessary if the request seeks additional coverage: extending timeline, adding units, adding line-items or changing CPT codes.

1. This form must indicate the changes(s) being sought. Check boxes for all applicable changes being sought.

2. Requests for additional coverage must be submitted within the authorization timeline. A new PA request must be submitted after the authorization timeline.

 

Oklahoma ABLE Tech Reutilization Program Update

Oklahoma ABLE Tech has enhanced two key activities of their Device Reutilization Program:

  • Reopening of the Smart Home Demonstration Site
    Oklahoma ABLE Tech's OKC Smart Home Demonstration site is now open again. If you're interested in assistive, smart home or enabling technology for your home, schedule a tour of the site. Tours are available in person or virtually from 1-4 p.m. every Thursday. Bethany Potts oversees the smart home tours, and she can also provide hearing assistive technology consultations.

  • New Collaboration with Oklahoma Human Services
    Oklahoma ABLE Tech is partnering with the Oklahoma Department of Human Services' Client Assistance Program (OK DHS CAP). CAP will support the Durable Medical Equipment Reuse and Repair for Respite (R&R4R) initiative. This partnership will help Oklahoma ABLE Tech improve their Device Reutilization Program to serve Oklahomans who care for their family and friends.

    The R&R4R initiative helps ABLE Tech to repair, redistribute, demo and train on durable medical equipment (DME). They aim to improve life for caregivers and those they care for and do this by providing or maintaining vital equipment that helps in caregiving. DME is crucial for in-home caregiving. It improves patient care and gives caregivers a much-needed respite. Careful selection, proper use, and diligent maintenance of DME can ensure a balanced and sustainable caregiving environment. As caregiving dynamics change, integrating DME will be vital to support both caregivers and patients. 

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