Okla. Admin. Code § 317:30-5-566

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-566 - Ambulatory Surgery Center services

(a)Reimbursement. Reimbursement is made for selected services based on the Medicare approved list of covered services that can be performed at an ASC. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA. Ambulatory surgery center services are paid on a rate-per-service basis that varies according to the Health Care Procedure Coding System (HCPCS) codes. Separate payments may be made to the ASC for covered ancillary services. To be considered a covered ancillary service for which separate payment is made, the items and services must be provided integral to covered surgical procedures, that is, immediately before, during, or immediately after the covered surgical procedure.

(b)Multiple surgeries. Multiple procedures furnished during the same visit are discounted. The full amount is paid for the procedure with the highest payment rate. Fifty percent is paid for any other procedure(s) performed at the same time if the procedure is subject to discounting based on the discount indicator established by Medicare.

(c)Payment indicators. Payment indicators identify whether the service described by a HCPCS code is paid under the ASC methodology and if so, whether payment is made separately or packaged. SoonerCare follows Medicare's guidelines for packaged/bundled service costs.

(d)Minor procedures. Minor procedures that are normally performed in a physician's office are not covered in an ambulatory surgery center unless medically necessary and they are on the Medicare list for procedures approved to be performed in an ASC. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA.

(e)Dental Procedures. For OHCA payment purposes, the ASC list has been expanded to cover dental services for adults in an ICF/MR and all children.

(1) Non-emergency routine dental that is provided in an ambulatory surgery center is covered for children under the following circumstances:

(A) The child has a medical history of uncontrolled bleeding or other medical condition renders in-office treatment impossible.

(B) The child has uncontrollable behavior in the dental office even with premedication.

(C) The child needs extensive dental procedures or oral surgery procedures.

(2) Non-emergency routine dental that is provided in an ambulatory surgical center is covered for children and/or adults who are residents in ICFs/MR only under the following circumstances:

(A) A concurrent hazardous medical condition exists;

(B) The nature of the procedure requires hospitalization; or

(C) Other factors (e.g. behavioral problems due to mental impairment) necessitate hospitalization.

Okla. Admin. Code § 317:30-5-566

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 19 Ok Reg 2134, eff 6-27-02; Amended at 20 Ok Reg 2881, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 23 Ok Reg 2487, eff 6-25-06; Amended at 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff 5-11-07; Amended at 25 Ok Reg 2698, eff 7-25-08; Amended at 26 Ok Reg 527, eff 1-2-09 (emergency); Amended at 26 Ok Reg 2117, eff 6-25-09; Amended at 27 Ok Reg 705, eff 2-4-10 (emergency); Amended at 27 Ok Reg 1457, eff 6-11-10