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OHCA Policies and Rules

317:30-5-96.2. Payments definitions

[Revised 09-14-2020]

The following words and terms, when used in OAC 317:30-5-96.3 through 317:30-5-96.7, shall have the following meaning, unless the context clearly indicates otherwise:

"Add-on payment" means an additional payment added to the per diem to recognize the increased cost of serving members with complex needs in a PRTF or Acute II.

"Allowable costs" means costs necessary for the efficient delivery of member care.

"Ancillary services" means the services for which charges are customarily made in addition to routine services. Ancillary services include, but are not limited to, physical therapy, speech therapy, laboratory, radiology, and prescription drugs.

"Border status" means a placement in a state that does not border Oklahoma. Reimbursement for out-of-state services is made in accordance with OAC 317:30-3-89 through 317:30-3-92 and the Oklahoma Medicaid State Plan.

"Developmentally disabled child" means a child with deficits in adaptive behavior originating during the developmental period. This condition may exist concurrently with a significantly subaverage general intellectual functioning.

"Eating disorder programs" means acute or intensive residential behavioral, psychiatric, and medical services provided in a discreet unit to individuals experiencing an eating disorder.

"Professional services" means services of a physician, psychologist, or dentist legally authorized to practice medicine and/or surgery by the state in which the function is performed.

"Routine services" means services that are considered routine in the Acute II and PRTF levels of care setting. Routine services include, but are not limited to:

(A) Room and board;

(B) Treatment program components;

(C) Psychiatric treatment;

(D) Professional consultation;

(E) Medical management;

(F) Crisis intervention;

(G) Transportation;

(H) Rehabilitative services;

(I) Case management;

(J) Interpreter services (if applicable);

(K) Routine health care for individuals in good physical health; and

(L) Laboratory services for a substance abuse/detoxification program.

"Specialty treatment program/specialty unit" means Acute or other intensive behavioral, psychiatric, and medical services that provide care to a population with special needs or issues such as developmentally disabled, intellectually disabled, autistic/Asperger's, eating disorders, sexual offenders, or reactive attachment disorders. These members require a higher level of care and staffing ratio than a standard PRTF and typically have multiple problems.

"Treatment program components" means therapies, activities of daily living, and rehabilitative services furnished by physician/psychologist or other licensed mental health professionals.

"Usual and customary charges" means the uniform charges listed in a provider's established charge schedule which is in effect and applied consistently to most members and recognized for program reimbursement. To be considered "customary" for reimbursement, a provider's charges for like services must be imposed on most members regardless of the type of member treated or the party responsible for payment of such services.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.