SECTION 317:25-7-30. Obtaining SoonerCare Choice services

(a)   Medical services which are not the responsibility of the primary care provider (PCP) to authorize under the care coordination component of SoonerCare Choice, as described in Oklahoma Administrative Code (OAC) 317:25-7-10(b), are obtained in the same manner as under the regular SoonerCare fee-for-service program.

(b)   For policy regarding out-of-state transportation for primary and specialty care, refer to OAC 317:30-3-89 through 317:30-3-92.

(c)   An American Indian/Alaska Native (AI/AN) eligible SoonerCare member may choose a PCP from the provider directory, including the Indian Health Service (IHS), tribal and urban Indian clinics that participate as SoonerCare PCPs. An AI/AN member in SoonerCare may enroll with a PCP who is not an IHS, tribal, or urban Indian clinic and still use the IHS, tribal, or urban Indian clinic for medical care. A referral from a PCP is needed for services that the clinic cannot provide, except for self-referred services.

(d)   If an IHS, tribal, or urban Indian clinic is unable to deliver a service to a SoonerCare enrollee and must refer the member for the service to a non-IHS, tribal, or urban Indian clinic, SoonerCare reimbursement is made only to the specialist when the service has been referred by a PCP, unless PCP authorization is not required under OAC 317:25-7-2 (c).

(e)   A PCP is not obligated to provide emergency services and is not responsible for authorization or approval for payment for members seen in the emergency room. A PCP may not require members to seek prior authorization (PA) for emergency services. However, a PCP may provide emergency care in an emergency setting, within his/her legal scope of practice.

(f)   A PA is required for some medical procedures, equipment, medications, and specialty services. The PCP and/or requesting provider are responsible for submitting the PA request to SoonerCare. The member and requesting provider will be notified of SoonerCare's decision to authorize the requested services. A PA is not a guarantee of payment.

[Source: Added at 13 Ok Reg 587, eff 11-21-95 (emergency); Added at 13 Ok Reg 1633, eff 5-27-96; Amended at 13 Ok Reg 3565, eff 7-16-96 (emergency); Amended at 14 Ok Reg 745, eff 12-24-96 (emergency); Amended at 14 Ok Reg 1776, eff 5-27-97; Amended at 14 Ok Reg 3061, eff 7-1-97 (emergency); Amended at 15 Ok Reg 1511, eff 5-11-98; Amended at 21 Ok Reg 2149, eff 6-25-04; Amended at 26 Ok Reg 401, eff 1-1-09 (emergency); Amended at 26 Ok Reg 2074, eff 6-25-09; Amended at 37 Ok Reg 1471, eff 9-14-20]