SECTION 317:30-5-216. Prior authorization requests

(a)   Prior authorization requirements. Requirements vary for different types of services. Providers should refer to the service-specific sections of policy or the OHCA website for services requiring PA.

(1)   Required forms. All required forms are available on the OHCA web site at www.okhca.org.

(2)   Certificate of medical necessity. The prescribing provider must complete the medical necessity section of the CMN. This section cannot be completed by the supplier. The medical necessity section can be completed by any health care clinician; however, only the member's treating provider may sign the CMN. By signing the CMN, the physician is validating the completeness and accuracy of the medical necessity section. The member's medical records must contain documentation substantiating that the member's condition meets the coverage criteria and the answers given in the medical necessity section of the CMN. These records may be requested by OHCA or its representatives to confirm concurrence between the medical records and the information submitted with the prior authorization request.

(b)   Submitting prior authorization requests. Contact information for submitting prior authorization requests may be found in the OHCA Provider Billing and Procedures Manual. An electronic version of this manual is located on the OHCA web site.

(c)   Prior authorization review. Upon verifying the completeness and accuracy of clerical items, the PA request is reviewed by OHCA staff to evaluate whether or not each service being requested meets SoonerCare's definition of "medical necessity" [see OAC 317:30-3-1 (f)] as well as other criteria.

(d)   Prior authorization decisions. After the PA request is processed, a notice will be issued regarding the outcome of the review. If the request is approved the notice will include an authorization number, the appropriate date span and procedure codes approved.

(e)   Prior authorization does not guarantee reimbursement. Provider status, member eligibility, and medical status on the

date of service, as well as all other SoonerCare requirements, must be met before the claim is reimbursed.

(f)   Prior authorization of manually-priced items. Manually-priced items must be prior authorized. If manual pricing is used, the provider is reimbursed at the provider's documented Manufacturer's Suggested Retail Price (MSRP) minus 30% or invoice cost plus 30%, whichever is the lesser of two. OHCA may establish a fair market price through claims review and analysis.

[Source: Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Revoked at 18 Ok Reg 477, eff 1-1-01 (emergency); Revoked at 18 Ok Reg 1130, eff 5-11-01; Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at 26 Ok Reg 256, eff 12-1-08 (emergency); Amended at 26 Ok Reg 1062, eff 5-11-09; Amended at 27 Ok Reg 453, eff 12-3-09 (emergency); Amended at 27 Ok Reg 942, eff 5-13-10; Amended at 31 Ok Reg 1644, eff 9-12-14]