OHCA Policies and Rules
317:30-5-1030. Eligible providers
[Revised 09-12-14]
(a) Case management providers. Services are provided by case managers certified by the State Department of Education as meeting the requirements for providing case management. SoonerCare School-Based Targeted Case Management (SBTCM) services must be made available to all eligible members and must be delivered on a statewide basis with procedures that ensure continuity of service without duplication and in compliance with federal and state mandates and regulations related to servicing the targeted population in a uniform and consistent manner. The case managers must be certified by the single state Medicaid agency as meeting the following:
(1) a minimum of five (5) years experience in meeting the case management and service needs of the target population.
(2) a minimum of five (5) years experience in providing all core elements of case management services, including:
(A) individualized strengths and needs assessment;
(B) needs-based service planning;
(C) service coordination, monitoring and advocacy;
(D) service plan review; and
(E) crisis assistance planning.
(3) a minimum of five (5) years experience in developing and implementing Individualized Education Programs (IEP) and/or Individualized Family Service Plans (IFSP) and in meeting the requirements of the IDEA, in accordance with State and Federal law. Each IEP and/or IFSP is dependent upon the needs of the individual student as determined by consultation that may include any or all of the professions in (A) through (F) of this paragraph. Those providing input must meet state or national licensure, registration or certification requirements of the profession in which they practice and include:
(A) special education,
(B) school psychologist,
(C) occupational therapist,
(D) physical therapist,
(E) speech language specialist, or
(F) school counselor and other specialists as identified.
(4) a demonstrated ability to collaborate with public and private services providers.
(5) experience in providing and coordinating education support services, including but not limited to Student Assistance, Special Education, Psychology and Counseling Services.
(6) adequate administrative capacity to fulfill state and federal requirements.
(7) a financial management capacity and system that provides documentation of services and costs.
(8) a capacity to document and maintain individual case records in accordance with state and federal requirements.
(9) a demonstrated ability to meet all state and federal laws governing participation of providers in the SoonerCare program including, but not limited to, the ability to meet federal and state requirements for documentation, billing and audits.
(b) Provider agreement. A Provider Agreement between the Oklahoma Health Care Authority and the providers for case management services must be in effect before reimbursement can be made for compensable services.
(c) Qualifications of individual case managers. A targeted case manager for the SBTCM program must:
(1) be employed by the school or their contractor;
(2) possess an appropriate certificate, or meet other comparable requirements as applicable to the profession or discipline in which a person is providing special education, early intervention or related services, in accordance with the requirements of the Oklahoma State Department of Education; or
(3) be licensed, certified or registered as a health care professional in the State, and meet the qualifications for related services staff under the most current provisions of Part B or Part C of the Individuals with Disabilities Education Act.
(d) Provider selection. Provision of case management services must not restrict an individual's free choice of providers. Eligible members must have free choice of the providers of other medical care under the plan.
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.
