SECTION 317:30-5-356. Coverage for adults

  Payment is made to rural health clinics for adult services as set forth in this Section.

(1)   RHC services. Payment is made for one encounter per member per day. Payment is also limited to four visits per member per month. Refer to OAC 317:30-1, General Provisions, and OAC 317:30-3-65.2 for exceptions to the four visit limit for children under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). Additional preventive service exceptions include:

(A)   Obstetrical care. A Rural Health Clinic should have a written contract with its physician, certified nurse midwife, advanced practice nurse, or physician assistant that specifically identifies how obstetrical care will be billed to SoonerCare, in order to avoid duplicative billing situations. The agreement should also specifically identify the physician's compensation for rural health and non-rural health clinic (other ambulatory) services.

(i)   If the clinic compensates the physician, certified nurse midwife or advanced practice nurse to provide obstetrical care, then the clinic must bill the SoonerCare program for each prenatal visit using the appropriate CPT evaluation and management codes.

(ii)   If the clinic does not compensate its practitioners to provide obstetrical care, then the independent practitioner must bill the OHCA for prenatal care according to the global method described in the SoonerCare provider specific rules for physicians, certified nurse midwives, physician assistants, and advanced practice nurses (refer to OAC 317:30-5-22).

(iii)   Under both billing methods, payment for prenatal care includes all routine or minor medical problems. No additional payment is made to the prenatal provider except in the case of a major illness distinctly unrelated to pregnancy.

(B)   Family planning services. Family planning services are available only to members with reproductive capability. Family planning visits do not count as one of the four RHC visits per month.

(2)   Other ambulatory services. Services defined as "other ambulatory" services are not considered a part of a RHC visit and are therefore billable to the SoonerCare program by the RHC or provider of service on the appropriate claim forms. Other ambulatory services are subject to the same scope of coverage as other SoonerCare services billed to the program, i.e., limited adult services and some services for under 21 subject to same prior authorization process. Refer to OAC 317:30-1, General Provisions, and OAC 317:30-3-57, 317:30-5-59, and 317:30-3-60 for general coverage and exclusions under the SoonerCare program. Some specific limitations are applicable to other ambulatory services as set forth in specific provider rules and excerpted as follows: Coverage under optometrists for adults is limited to treatment of eye disease not related to refractive errors. There is no coverage for eye exams for the purpose of prescribing eyeglasses, contact lenses or other visual aids. (See OAC 317:30-5-431.)

[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; Amended at 13 Ok Reg 397, eff 11-14-95 (emergency); Amended at 13 Ok Reg 1645, eff 5-27-96; Amended at 16 Ok Reg 141, eff 10-14-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 21 Ok Reg 501, eff 1-1-04 (emergency); Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 23 Ok Reg 2463, eff 6-25-06; Amended at 26 Ok Reg 113, eff 8-1-08 (emergency); Amended at 26 Ok Reg 1066, eff 5-11-09; Amended at 31 Ok Reg 657, eff 7-1-14 (emergency); Amended at 32 Ok Reg 1069, eff 8-27-15; Amended at 33 Ok Reg 846, eff 9-1-16; Amended at 34 Ok Reg 192, eff 11-22-16 (emergency); Amended at 34 Ok Reg 657, eff 9-1-17]