OHCA fixes denial of inpatient psychiatric claims

Posted on: 9/13/19

The Oklahoma SoonerCare (Medicaid) program has incorrectly denied certain hospital claims under a psychiatric prior-authorization program, and is correcting this error.  

The Oklahoma Health Care Authority (OHCA) introduced a prior authorization (PA) policy for inpatient psychiatric services in September 2018, but applied the PA requirement too broadly. SoonerCare hospital claims for the inpatient medical treatment of drug overdoses were inappropriately denied. The Oklahoma Hospital Association worked with OHCA on this issue after learning of the problem from members.

In Provider Letter 2019-17, OHCA clarified this week that inpatient psychiatric services in the SoonerCare program require prior authorization when provided in a psychiatric unit of a general hospital. Prior authorization is not required for psychiatric or medical detoxification services provided to adults in a non-psychiatric unit setting of a general hospital.  

Hospitals that filed a claim with a mental health or substance abuse principal diagnosis for SoonerCare members who received services in a non–psychiatric unit setting and received a denial with the explanation “NO PA ON THE DATABASE” should refile the claim immediately to receive payment, assuring all other requirements are met.

For additional information, see OHCA Provider Letter 2019-17. (Rick Snyder)