SECTION 317:30-5-547. Reimbursement

(a)   Nursing services and home health aide services are covered services on a per visit basis. Reimbursement for any combination of nursing or home aid service shall not exceed 36 visits per calendar year per member. Additional visits for children must be prior authorized when medically necessary.

(b)   Reimbursement for durable medical equipment and supplies will be made using the amount derived from the lesser of the OHCA fee schedule or the provider's usual and customary charge. The maximum allowable fee is the maximum amount that OHCA will pay a provider for an allowable procedure code. When a procedure code is not assigned a maximum allowable fee for a unit of service, a fee will be established. Once the service has been provided, the supplier is required to include a copy of the invoice documenting the supplier's cost of the item with the claim.

(c)   Reimbursement for oxygen and oxygen supplies is as follows:

(1)   Payment for oxygen systems (stationary, liquid and oxygen concentrators) is based on continuous rental, i.e., a continuous monthly payment is made as long as it is medically necessary. The rental payment includes all contents and supplies, i.e., regulators, tubing, masks, etc. Portable oxygen systems are also considered continuous rental. Ownership of the equipment remains with the supplier.

(2)   Separate payment will not be made for maintenance, servicing, delivery, or for the supplier to pickup the equipment when it is no longer medically necessary.

(3)   Payment for oxygen and oxygen equipment and supplies will not exceed the Medicare fee for the same procedure code. Reimbursement for members who reside in a nursing facility may be at a reduced rate. The fee schedule will be reviewed annually and adjustments to the fee schedule may be made at any time based on efficiency, budget considerations, and quality of care as determined by the OHCA.

[Source: Amended at 16 Ok Reg 3451, eff 7-1-99 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 20 Ok Reg 374, eff 1-1-03 (emergency); Amended at 20 Ok Reg 1920, eff 6-26-03; Amended at 24 Ok Reg 2890, eff 7-1-07 (emergency); Amended at 25 Ok Reg 1161, eff 5-25-08; Amended at 27 Ok Reg 628, eff 14-13-10 (emergency); Amended at 27 Ok Reg 1451, eff 6-11-10]