Last updated 02/28/2021
Consent Requirements
There will be no dissemination of any member images or information to other entities without written consent from the member or member’s parent or legal guardian, if the member is a minor.
In order for OHCA to reimburse medically necessary telehealth services provided to SoonerCare members in a primary or secondary school setting, all of the telehealth requirements must be met, with the exception of the requirement that a parent or legal guardian being there to present the child, as well as all of the requirements shown below, as applicable.
Advance parent or legal guardian consent for telehealth services must be obtained for minors, in accordance with 25 O.S. ” 2004 through 2005. Additional consent requirements shall apply to school-based services.
For telehealth medical services provided in a primary or secondary school setting, the telehealth practitioner must provide a summary of the service, including, but not limited to, information regarding the exam findings, prescribed or administered medications, and patient instructions, to: (1) The SoonerCare member, if he or she is an adult, or the member’s parent or legal guardian, if the member is a minor; or (2) The SoonerCare member’s primary care provider, if requested by the member or the member’s parent or legal guardian.
Even though physical therapy, occupational therapy, and/or speech and hearing services are not subject to the notification requirements of OAC 317:30-3-27(d)(2), said services must still comply with all other State and Federal Medicaid requirements, in order to be reimbursable by Medicaid. Accordingly, for those physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c) 9 & (d). (Accessed Feb. 2021).
If the member is a minor, the provider must obtain the prior written consent of the member’s parent or legal guardian to provide services via telehealth, that includes, at a minimum, the name of the provider; the provider’s permanent business office address and telephone number; an explanation of the services to be provided, including the type, frequency, and duration of services. Written consent must be obtained annually, or whenever there is a change in the information in the written consent form, as set forth above. The parent or legal guardian need not attend the telehealth session unless attendance is therapeutically appropriate. The requirements of subsection OAC 317:30-3-27(c)(5), however, do not apply to telehealth services provided in a primary or secondary school setting. If the member is a minor, the telehealth provider shall notify the parent or legal guardian that a telehealth service was performed on the minor through electronic communication whether a text message or email.
For telehealth medical services provided in a primary or secondary school setting, the telehealth practitioner must provide a summary of the service, including, but not limited to, information regarding the exam findings, prescribed or administered medications, and patient instructions, to:
- The SoonerCare member, if he or she is an adult, or the member’s parent or legal guardian, if the member is a minor; or
- The SoonerCare member’s primary care provider, if requested by the member or the member’s parent or legal guardian.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(5) & (d)(2). (Accessed Feb. 2021).
Last updated 02/28/2021
Definitions
For purposes of SoonerCare reimbursement, telehealth is the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment that occur in real-time and when the member is actively participating during the transmission.
SOURCE: Health Care Authority, Providers, Telehealth. (Accessed Feb. 2021).
“Telehealth” means the practice of health care delivery, diagnosis, consultation, evaluation and treatment, transfer of medical data or exchange of medical education information by means of a two-way, real-time interactive communication, not to exclude store and forward technologies, between a patient and a health care provider with access to and reviewing the patient’s relevant clinical information prior to the telemedicine visit. Telehealth shall not include consultations provided by telephone audio-only communication, electronic mail, text message, instant messaging conversation, website questionnaire, nonsecure video conference, or facsimile transmission.
“Telehealth medical service” means, for the purpose of the notification requirements of OAC 317:30-3-27(d)(2), telehealth services that expressly do not include physical therapy, occupational therapy, and/or speech and hearing services.
SOURCE: OK Admin. Code Sec. 317:30-3-27 (a(4)). (Accessed Feb. 2021).
Last updated 02/28/2021
Email, Phone & Fax
No reimbursement for email.
No reimbursement for telephone.
No reimbursement for FAX.
SOURCE: OK Admin. Code Sec. 317:30-3-27(a). (Accessed Feb. 2021).
Last updated 02/28/2021
Live Video
POLICY
SoonerCare (Oklahoma’s Medicaid program) reimburses for live video when:
- Provider is contracted with SoonerCare and appropriately licensed
- The GT modifier is billed
Proper documentation of services rendered to include: service rendered, location at which service was rendered, and that service was provided via telehealth. (Documentation of services must follow all other SoonerCare documentation guidelines as well.)
SOURCE: OK Health Care Authority, Telehealth. (Accessed Feb. 2021).
ELIGIBLE SERVICES/SPECIALTIES
OHCA has discretion and final authority to approve or deny telehealth services based on agency and/or SoonerCare members’ needs. See Medicaid Telehealth webpage for a link to a full list of eligible CPT Codes for Medical and Behavioral Health Services. Services provided by telehealth must be billed with the appropriate modifier.
SOURCE: OK Admin. Code Sec. 317:30-3-27 & Health Care Authority, Providers, Telehealth. (Accessed Feb. 2021).
A telehealth service is subject to the same SoonerCare program restrictions, limitations, and coverage which exist for the service when not provided through telehealth; provided, however, that only certain telehealth codes are reimbursable by SoonerCare. For a list of the SoonerCare-reimbursable telehealth codes, refer to the OHCA’s Behavioral Health Telehealth Services and Medical Telehealth Services, available on OHCA’s website, www.okhca.org.
Where there are established service limitations, the use of telehealth to deliver those services will count towards meeting those noted limitations. Service limitations may be set forth by Medicaid and/or other third-party payers.
SOURCE: OK Admin. Code Sec. 317:30-3-27. (Accessed Feb. 2021).
Physical, Occupational and Speech and Hearing Services
For physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.
SOURCE: OK Admin. Code Sec. 317:30-3-27(d). (Accessed Feb. 2021).
Behavioral Health
See SoonerCare behavioral health fee schedule for reimbursable telemedicine services.
SOURCE: Oklahoma Health Care Authority, Behavioral Health Services Reimbursable via telemedicine. Updated July 18, 2018. (Accessed Feb. 2021).
Psychiatric services performed via telemedicine are subject to the requirements found in Oklahoma Administrative Code (OAC) 317:30-3-27.
SOURCE: OK Admin. Code Sec. 317:30-5-11 – Psychiatric services. (Accessed Feb. 2021).
ELIGIBLE PROVIDERS
To participate, a provider must:
- Be contracted with SoonerCare and appropriately licensed
- Bill for services using the appropriate modifier (GT)
- Maintain documentation of services, to include: service rendered, location at which service was rendered, and that service was provided via telemedicine. (Documentation of services must follow all other SoonerCare documentation guidelines as well.)
SOURCE: Oklahoma Health Care Authority, Telehealth. (12/03/20). (Accessed Feb. 2021).
The provider must be contracted with SoonerCare and appropriately licensed or certified, in good standing. Services that are provided must be within the scope of the practitioner’s license or certification. If the provider is outside of Oklahoma, the provider must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(3). (Accessed Feb. 2021).
Certain outpatient behavioral health services are only reimbursed when provided by a licensed psychiatrist, certified mobile crisis team or an inpatient psychiatric facility.
SOURCE: Oklahoma Health Care Authority, Behavioral Health Services Reimbursable via telemedicine. Updated July 18, 2018. (Accessed Feb. 2021).
Indian Health Service/Tribal 638
An I/T/U encounter means a face to face or telehealth contact between a health care professional and an IHS eligible SoonerCare member for the provision of medically necessary Title XIX or Title XXI covered services through an IHS or Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at midnight, as documented in the patient’s record.
SOURCE: OK Admin. Code Sec. 317:30-5-1098. I/T/U outpatient encounters. (Accessed Feb. 2021).
ELIGIBLE SITES
The medical or behavioral health related service must be provided at an appropriate site for the delivery of telehealth services. An appropriate telehealth site is one that has the proper security measures in place; the appropriate administrative, physical, and technical safeguards should be in place that ensures the confidentiality, integrity, and security of electronic protected health information. The location of the room for the encounter at both ends should ensure comfort, privacy, and confidentiality. Both visual and audio privacy are important, and the placement and selection of the rooms should consider this. Appropriate telehealth equipment and networks must be used considering factors such as appropriate screen size, resolution, and security. Providers and/or members may provide or receive telehealth services outside of Oklahoma when medically necessary; however, prior authorization may be required.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(3). (Accessed Feb. 2021).
School Setting
In order for OHCA to reimburse medically necessary telehealth services provided to SoonerCare members in a primary or secondary school setting, all of the requirements in (c) above must be met, with the exception of (c)(5), as well as all of the requirements shown below, as applicable. There are special consent and notification requirements for school-based sites. See Oklahoma Code.
Physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.
SOURCE: OK Admin. Code Sec. 317:30-3-27(d). (Accessed Feb. 2021).
GEOGRAPHIC LIMITS
No Reference Found
FACILITY/TRANSMISSION FEE
The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.
SOURCE: OK Admin. Code Sec. 317:30-3-27(e)(4). (Accessed Feb. 2021).
Last updated 02/28/2021
Miscellaneous
All telehealth activities must comply with Oklahoma Health Care Authority (OHCA) policy, and all other applicable State and Federal laws and regulations.
See administrative code for specific documentation requirements.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(8) & (f). (Accessed Feb. 2021).
Health Access Networks (HANs) must Facilitate members’ access to all levels of care, including primary, outpatient, specialty, certain ancillary services, and acute inpatient care, within a community or across a broad spectrum of providers across a service region or the state through improved access to specialty care, telehealth, and expended quality improvement strategies.
SOURCE: OK Admin. Code Sec. 317:25-9-2. (Accessed Feb. 2021).
Last updated 02/28/2021
Out of State Providers
The provider must be contracted with SoonerCare and appropriately licensed or certified, in good standing. Services that are provided must be within the scope of the practitioner’s license or certification. If the provider is outside of Oklahoma, the provider must comply with all laws and regulations of the provider’s location, including health care and telehealth requirements.
Providers and/or patients may provide or receive telehealth services outside of Oklahoma when medically necessary, however prior authorization may be required.
SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(3 & 4). (Accessed Feb. 2021).
Last updated 02/28/2021
Overview
SoonerCare reimburses for live video telehealth. Store-and-Forward and Remote Patient Monitoring must be compensable by the Oklahoma Health Care Authority (OHCA) in order to be reimbursed.
Last updated 02/28/2021
Remote Patient Monitoring
POLICY
“Remote patient monitoring” means the use of digital technologies to collect medical and other forms of health data (e.g. vital signs, weight, blood pressure, blood sugar) from individuals in one (1) location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations.
Health care services delivered by telehealth such as remote patient monitoring, store-and-forward, or any other telehealth technology must be compensable by OHCA in order to be reimbursed.
Services provided by telehealth must be billed with the appropriate modifier.
The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.
SOURCE: OK Admin. Code Sec. 317:30-3-27(a) & (e). (Accessed Feb. 2021).
Continuous glucose monitoring (CGM)
CGM means a minimally invasive system that measures glucose levels in subcutaneous or interstitial fluid. CGM provides blood glucose levels and can help members make more informed management decisions throughout the day.
CGM must be determined by a provider to be medically necessary and documented in the member’s plan of care as medically necessary and used for medical purposes. A request by a medical provider for CGM in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity. CGM devices must be approved by the U.S. Food and Drug Administration (FDA) as non-adjunctive and must be used for therapeutic purposes. Devices may only be used for members within the age range for which the devices have been FDA approved.
CGM patients must have an in-person or telehealth visit within 6 months between the treating provider, member and/or family to evaluate their diabetes control.
SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Feb. 2021).
CONDITIONS
Continuous glucose monitoring (CGM)
Member must have a diagnosis that correlates to the use of CGM.
SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Feb. 2021).
PROVIDER LIMITATIONS
Continuous glucose monitoring (CGM)
Prescription must be made by a physician, physician assistant, or an advanced practice registered nurse.
SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Feb. 2021).
OTHER RESTRICTIONS
No Reference Found
Last updated 02/28/2021
Store and Forward
POLICY
Health care services delivered by telehealth such as remote patient monitoring, store-and-forward, or any other telehealth technology must be compensable by OHCA in order to be reimbursed.
Services provided by telehealth must be billed with the appropriate modifier.
If the technical component of an X-ray, ultrasound or electrocardiogram is performed during a telehealth transmission, the technical component can be billed by the provider that provided that service. The professional component of the procedure and the appropriate visit code should be billed by the provider that rendered that service.
SOURCE: OK Admin. Code Sec. 317:30-3-27(e). (Accessed Feb. 2021).
“Store and forward technologies” means the transmission of a patient’s medical information from an originating site to the health care provider at the distant site; provided, photographs visualized by a telecommunications system shall be specific to the patient’s medical condition and adequate for furnishing or confirming a diagnosis or treatment plan. Store and forward technologies shall not include consultations provided by telephone audio-only communication, electronic mail, text message, instant messaging conversation, website questionnaire, nonsecure video conference, or facsimile transmission.
SOURCE: OK Admin. Code Sec. 317:30-3-27 (a). (Accessed Feb. 2021).
ELIGIBLE SERVICES/SPECIALTIES
No Reference Found
GEOGRAPHIC LIMITS
No Reference Found
TRANSMISSION FEE
The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.
SOURCE: OK Admin. Code Sec. 317:30-3-27(e)(4). (Accessed Feb. 2021).
