SECTION 317:30-5-1031. Coverage by category

(a)   Payment is made for case management services to children as set forth in this Section.

(1)   Description of case management services. The target group for case management services is individuals 0-21 who are receiving services pursuant to an Individualized Education Program (IEP), an Individualized Family Service Plan (IFSP), a Section 504 Accommodation Plan, or an Individualized Health Service Plan (IHSP), and who have a disability or are medically at risk. A disability is defined as a physical or mental impairment that substantially limits one or more major life activities. Medically at risk refers to individuals who have a diagnosable physical or mental condition that has a high probability of impairing cognitive, emotional, neurological, social or physical development.

(A)   Services are provided to assist the target population in gaining access to needed medical, social, educational, and other services. Major components of the service include:

(i)   Individualized needs assessment

(ii)   Needs-based service planning;

(iii)   Service coordination, monitoring and advocacy;

(iv)   Services plan review; and

(v)   Crisis assistance planning.

(B)   Case record documentation of the service components listed in (1) of this subsection is included as a case management activity. The client has the right to refuse case management and cannot be restricted from services because of a refusal for Case Management Services.

(C)   Case management does not include:

(i)   Program activities of the agency itself that do not meet the definition of case management.

(ii)   Administrative activities necessary for the operation of the agency providing case management services other than the overhead costs directly attributable to targeted case management.

(iii)   Diagnostic, treatment or instructional services, including academic testing.

(iv)   Services that are an integral part of another service already reimbursed by SoonerCare.

(v)   Activities that are an essential part of SoonerCare administration, such as outreach, intake processing, eligibility determination or claims processing.

(2)   Non-duplication of services. To the extent any eligible members in the identified targeted population are receiving TCM services from another provider agency as a result of being members of other covered targeted groups, the providers assures that case management activities are coordinated to avoid unnecessary duplication of service. To the extent any of the services required by the member are a SoonerCare covered benefit of a managed care organization of which the client is a member, the provider will assure that timely referrals are made and that coordination of care occurs.

(3)   Providers. Case management services must be provided by the schools or their contractors.

(b)   Individuals eligible for Part B of Medicare. Case Management Services provided to Medicare eligible members are filed directly with the fiscal agent.

[Source: Added at 16 Ok Reg 1927, eff 6-11-99; Amended at 19 Ok Reg 63, eff 9-1-01 (emergency); Amended at 19 Ok Reg 2127, eff 6-27-02; Amended at 31 Ok Reg 1684, eff 9-12-14]