Okla. Admin. Code § 317:30-5-567

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

Section 317:30-5-567 - Coverage by category

Payment is made for ambulatory surgical center services as set forth in this Section.

(1)Children. Payment is made for children for medically necessary surgical procedures which are included on Medicare's list of covered ASC surgical procedures and dental procedures in certain circumstances. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the Oklahoma Health Care Authority (OHCA).

(A) Services, deemed medically necessary and allowable under federal regulations, may be covered by the EPSDT/OHCA Child Health program even though those services may not be part of the OHCA SoonerCare program. Such services must be prior authorized.

(B) Federal regulations also require the State to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or which are considered experimental.For more information regarding experimental or investigational including clinical trials, see Oklahoma Administrative Code 317:30-3-57.1.

(2)Adults. Payment is made for adults for medically necessary surgical procedures which are included on Medicare's list of covered ASC surgical procedures. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA.

(3)Individuals eligible For Part B of Medicare. Payment is made utilizing the OHCA allowable for comparable services.

Okla. Admin. Code § 317:30-5-567

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 19 Ok Reg 2922, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff 5-11-07; 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

Amended by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/1/2021