SECTION 317:35-15-8.1. Agency Personal Care services; billing, and problem resolution

  The ADvantage Administration (AA) certifies qualified personal care provider agencies and facilitates the execution of the agencies' SoonerCare contracts on behalf of the Oklahoma Health Care Authority (OHCA). OHCA checks the list of providers barred from Medicare/SoonerCare participation to ensure that the personal care services agency is not listed.

(1)   Payment for personal care. Payment for personal care services is made for care provided in the member's "own home" or in other limited types of living arrangements per OAC 317:35-15-2(b)(1 through 4).

(A)   Use of provider agency. To provide personal care services, an agency must be licensed by the Oklahoma State Department of Health, meet certification standards identified by the Oklahoma Department of Human Services (DHS), and possess a current SoonerCare contract.

(B)   Reimbursement. Personal care services payment on behalf of a member is made according to the type of service and number of units of personal care services authorized in the Service Authorization Model (SAM) packet.

(i)   The amount paid to provider agencies for each unit of service is according to established SoonerCare rates for the Personal Care services. Only authorized units contained in each eligible member's individual SAM packet are eligible for reimbursement. Provider agencies serving more than one personal care service member residing in the same residence ensure the members' SAM packets combine units in the most efficient manner to meet the needs of all eligible persons in the residence.

(ii)   Payment for personal care services is for tasks performed in accordance per OAC 317:30-5-951 only when listed on an authorized plan of care. Payment for personal care skilled nursing service is made on behalf of the member for assessment/evaluation and associated service planning per SAM nursing visit.

(iii)   Service time for personal care services is documented through the use of the Electronic Visit Verification System (EVV), previously known as Interactive Voice Response Authentication (IVRA) system, when services are provided in the home.

(2)   Issue resolution.

(A)   The provider agency provides a written copy of their grievance process to each member at the commencement of services. The written grievance process includes the name and phone number of a provider agency contact person who is responsible for responding to such complaints and grievances. When the member is dissatisfied with the Personal Care provider agency or the assigned PCA and has exhausted attempts to work with the Personal Care provider agency's grievance process without resolution, the member is referred to the DHS State Plan Care Unit to attempt to resolve the issue(s). The member has the right to appeal to OHCA per OAC 317:2-1-2.

(B)   When a PCA performance issue is identified, provider agency staff conducts a counseling conference with the member and/or the PCA as appropriate. Provider agency staff counsels the PCA regarding problems with his/her performance.

(3)   Persons ineligible to serve as PCAs. Payment from SoonerCare funds for personal care services may not be made to an individual who is a legally responsible family member of the member, such as a spouse, legal guardian, or parent of minor child, to whom he/she is providing personal care services (exceptions may be made for legal guardians with prior approval from the Department of Human Services/Aging Services (DHS/AS).

[Source: Added at 20 Ok Reg 1069, eff 4-1-03 (emergency); Amended at 20 Ok Reg 1943, eff 6-26-03; Amended at 23 Ok Reg 817, eff 3-9-06 (emergency); Amended at 23 Ok Reg 2580, eff 6-25-06; Amended at 24 Ok Reg 95, eff 8-2-06 (emergency); Amended at 24 Ok Reg 945, eff 5-11-07; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency); Amended at 26 Ok Reg 758, eff 4-1-09 (emergency); Amended at 26 Ok Reg 2140, eff 6-25-09; Amended at 26 Ok Reg 758, eff 4-1-09 (emergency); Amended at 27 Ok Reg 308, eff 11-3-09 (emergency); Amended at 27 Ok Reg 972, eff 5-13-10; Amended at 32 Ok Reg 1142, eff 8-27-15; Amended at 34 Ok Reg 726, eff 9-1-17]