SECTION 317:25-7-5. Primary care providers (PCPs)

  For provision of health care services, the OHCA contracts with qualified PCPs. All providers serving as PCPs must have a valid SoonerCare Fee-for-Service contract as well as an exercised SoonerCare Choice addendum. Additionally, all PCPs, excluding provider or physician groups must agree to accept a minimum capacity of patients; provided, however, this does not guarantee PCPs a minimum patient volume. PCPs are limited to:

(1)   Physicians. Any physician licensed to practice medicine in the state in which he or she practices who is engaged in a general practice or in family medicine, general internal medicine or general pediatrics may serve as a PCP.

(A)   For physicians serving as SoonerCare Choice PCPs, the State caps the number of members per physician at two thousand, five hundred (2,500). If a physician practices at multiple sites, the capacity at each site is determined based on the number of hours per week the physician holds office hours, not to exceed one (1) FTE. Thus, the physician cannot exceed a maximum total capacity of two thousand, five hundred (2,500) members.

(B)   In areas of the state where cross-state utilization patterns have developed because of limited provider capacity in the state the OHCA may authorize contracts with out-of-state providers for PCP services. Out-of-state PCPs are required to comply with all access standards imposed on Oklahoma physicians, as well as Oklahoma Administrative Code (OAC) 317:30-3-89 through 317:30-3-92.

(2)   Advanced Practice Registered Nurses(APRNs). APRNs who have prescriptive authority may serve as PCPs for the Primary Care Case Management delivery system if licensed to practice in the state in which he or she practices. APRNs who have prescriptive authority may serve as PCPs for a maximum number of one thousand, two hundred and fifty (1,250) members.

(3)   Physician Assistants(PAs). PAs may serve as PCPs if licensed to practice in the state in which he or she practices. PAs may serve as PCPs for a maximum number of one thousand, two hundred and fifty (1,250) members.

(4)   Indian Health Service (IHS) Facilities and Federally Qualified Health Center (FQHC) provider groupsand Rural Health Clinics (RHC).

(A)   IHS facilities whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements at OAC 317:30-5-1088 may serve as PCPs.

(B)   FQHCs whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements in OAC 317:30-5-660.2 may serve as PCPs.

(C)   RHCs whose professional staff meet the general requirements in paragraphs (1) through (3) of this Section and the provider participation requirements in OAC 317:30-5-355 may serve as PCPs.

(5)   Provider or physician group capacity and enrollment.

(A)   Provider or physician groups must agree to accept a minimum enrollment capacity and may not exceed two thousand, five hundred (2,500) members per physician participating in the provider group.

(B)   If licensed PAs or APRNs are members of a group, the capacity may be increased by one thousand, two hundred and fifty (1,250) members if the provider is available full-time.

(C)   Provider or physician groups must designate a medical director to serve as the primary contact with OHCA.

[Source: Added at 14 Ok Reg 3061, eff 7-1-97 (emergency); Added at 15 Ok Reg 1511, eff 5-11-98; Amended at 15 Ok Reg 3778, eff 7-1-98 (emergency); Amended at 16 Ok Reg 138, eff 10-14-98 (emergency); Amended at 16 Ok Reg 1422, eff 5-27-99; Amended at 17 Ok Reg 425, eff 11-2-99 (emergency); Amended at 17 Ok Reg 2366, eff 6-26-00; Amended at 21 Ok Reg 2149, eff 6-25-04; Amended at 24 Ok Reg 2057, eff 6-25-07; Amended at 26 Ok Reg 401, eff 1-1-09 (emergency); Amended at 26 Ok Reg 2074, eff 6-25-09; Amended at 33 Ok Reg 790, eff 9-1-16; Amended at 37 Ok Reg 1471, eff 9-14-20]