2022 Oklahoma Statutes
Title 56. Poor Persons
§56-4002.2. Definitions.

As used in the Ensuring Access to Medicaid Act:

1. "Adverse determination" has the same meaning as provided by Section 6475.3 of Title 36 of the Oklahoma Statutes;

2. "Accountable care organization" means a network of physicians, hospitals, and other health care providers that provides coordinated care to Medicaid members;

3. "Claims denial error rate" means the rate of claims denials that are overturned on appeal;

4. "Capitated contract" means a contract between the Oklahoma Health Care Authority and a contracted entity for delivery of services to Medicaid members in which the Authority pays a fixed, per-member-per-month rate based on actuarial calculations;

5. "Children's Specialty Plan" means a health care plan that covers all Medicaid services other than dental services and is designed to provide care to:

• a.children in foster care,
• b.former foster care children up to twenty-five (25) years of age,
• c.juvenile justice involved children, and
• d.children receiving adoption assistance;

6. "Clean claim" means a properly completed billing form with Current Procedural Terminology, 4th Edition or a more recent edition, the Tenth Revision of the International Classification of Diseases coding or a more recent revision, or Healthcare Common Procedure Coding System coding where applicable that contains information specifically required in the Provider Billing and Procedure Manual of the Oklahoma Health Care Authority, as defined in 42 C.F.R., Section 447.45(b);

7. "Commercial plan" means an organization or entity that undertakes to provide or arrange for the delivery of health care services to Medicaid members on a prepaid basis and is subject to all applicable federal and state laws and regulations;

8. "Contracted entity" means an organization or entity that enters into or will enter into a capitated contract with the Oklahoma Health Care Authority for the delivery of services specified in the Ensuring Access to Medicaid Act that will assume financial risk, operational accountability, and statewide or regional functionality as defined in the Ensuring Access to Medicaid Act in managing comprehensive health outcomes of Medicaid members. For purposes of the Ensuring Access to Medicaid Act, the term contracted entity includes an accountable care organization, a provider-led entity, a commercial plan, a dental benefit manager, or any other entity as determined by the Authority;

9. "Dental benefit manager" means an entity that handles claims payment and prior authorizations and coordinates dental care with participating providers and Medicaid members;

10. "Essential community provider" means:

• a.a Federally Qualified Health Center,
• b.a community mental health center,
• c.an Indian Health Care Provider,
• d.a rural health clinic,
• e.a state-operated mental health hospital,
• f.a long-term care hospital serving children (LTCH-C),
• g.a teaching hospital owned, jointly owned, or affiliated with and designated by the University Hospitals Authority, University Hospitals Trust, Oklahoma State University Medical Authority, or Oklahoma State University Medical Trust,
• h.a provider employed by or contracted with, or otherwise a member of the faculty practice plan of:
• (1)a public, accredited medical school in this state, or
• (2)a hospital or health care entity directly or indirectly owned or operated by the University Hospitals Trust or the Oklahoma State University Medical Trust,
• i.a county department of health or city-county health department,
• j.a comprehensive community addiction recovery center,
• k.a hospital licensed by the State of Oklahoma including all hospitals participating in the Supplemental Hospital Offset Payment Program,
• l.a Certified Community Behavioral Health Clinic (CCBHC),
• m.a provider employed by or contracted with a primary care residency program accredited by the Accreditation Council for Graduate Medical Education,
• n.any additional Medicaid provider as approved by the Authority if the provider either offers services that are not available from any other provider within a reasonable access standard or provides a substantial share of the total units of a particular service utilized by Medicaid members within the region during the last three (3) years, and the combined capacity of other service providers in the region is insufficient to meet the total needs of the Medicaid members,
• o.a pharmacy or pharmacist, or
• p.any provider not otherwise mentioned in this paragraph that meets the definition of "essential community provider" under 45 C.F.R., Section 156.235;

11. "Material change" includes, but is not limited to, any change in overall business operations such as policy, process or protocol which affects, or can reasonably be expected to affect, more than five percent (5%) of enrollees or participating providers of the contracted entity;

12. "Governing body" means a group of individuals appointed by the contracted entity who approve policies, operations, profit/loss ratios, executive employment decisions, and who have overall responsibility for the operations of the contracted entity of which they are appointed;

13. "Local Oklahoma provider organization" means any state provider association, accountable care organization, Certified Community Behavioral Health Clinic, Federally Qualified Health Center, Native American tribe or tribal association, hospital or health system, academic medical institution, currently practicing licensed provider, or other local Oklahoma provider organization as approved by the Authority;

14. "Medical necessity" has the same meaning as provided by rules promulgated by the Oklahoma Health Care Authority Board;

15. "Participating provider" means a provider who has a contract with or is employed by a contracted entity to provide services to Medicaid members as authorized by the Ensuring Access to Medicaid Act;

16. "Provider" means a health care or dental provider licensed or certified in this state or a provider that meets the Authority's provider enrollment criteria to contract with the Authority as a SoonerCare provider;

17. "Provider-led entity" means an organization or entity that meets the criteria of at least one of following two subparagraphs:

• a.a majority of the entity's ownership is held by Medicaid providers in this state or is held by an entity that directly or indirectly owns or is under common ownership with Medicaid providers in this state, or
• b.a majority of the entity's governing body is composed of individuals who:
• (1)have experience serving Medicaid members and:
• (a)are licensed in this state as physicians, physician assistants, nurse practitioners, certified nurse-midwives, or certified registered nurse anesthetists,
• (b)at least one board member is a licensed behavioral health provider, or
• (c)are employed by:
• i.a hospital or other medical facility licensed by this state and operating in this state, or
• ii.an inpatient or outpatient mental health or substance abuse treatment facility or program licensed or certified by this state and operating in this state,
• (2)represent the providers or facilities described in division (1) of this subparagraph including, but not limited to, individuals who are employed by a statewide provider association, or
• (3)are nonclinical administrators of clinical practices serving Medicaid members;

18. "Statewide" means all counties of this state including the urban region; and

19. "Urban region" means:

• a.all counties of this state with a county population of not less than five hundred thousand (500,000) according to the latest Federal Decennial Census, and
• b.all counties that are contiguous to the counties described in subparagraph a of this paragraph,

combined into one region.

Added by Laws 2021, c. 542, § 2, eff. Sept. 1, 2021. Amended by Laws 2022, c. 395, § 2, eff. July 1, 2022; Laws 2022, c. 334, § 1, eff. July 1, 2022.