OHCA Policies and Rules

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317:35-3-1. Reimbursement

[Revised 09-01-15]

(a) Payment eligibility. In order for the Authority to make payment for SoonerCare services, the individual must be determined eligible to have such payment made by:

(1) having eligibility previously determined, or

(2) making application for SoonerCare at the time the medical services is requested, and having eligibility determined at that time.

(b) Member lock-in. SoonerCare members who have demonstrated utilization above the statistical norm, during a 6-month period, may be "locked-in" to a prescriber and/or one pharmacy for medications classified as controlled dangerous substances. If OHCA has determined that SoonerCare has been over-utilized, the member is notified, by letter, of the need to select a prescriber and/or pharmacy and of their opportunity for a fair hearing. If the member does not select a prescriber or pharmacy, one is selected for her/him. "Locked-in" membersmay obtain emergency services from a physician and/or an emergency room facility in the event of a medical emergency.

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.