The following are excluded from SoonerCare coverage for adults:
-
(1) Inpatient diagnostic studies that could be performed on an outpatient basis.
-
(2) Services or any expense incurred for cosmetic surgery.
-
(3) Services of two physicians for the same type of service to the same patient at the same time, except when warranted by the necessity of supplemental skills. When supplemental skills are warranted, the initial consultation is reported utilizing the appropriate CPT code for inpatient consultations. Follow-up consultations include monitoring progress, recommending management modifications or advising on a new plan of care in response to changes in the patient's status. If the consultant physician initiates treatment at the initial consultation and participates thereafter in the patient's care, the codes for subsequent hospital care should be used.
-
(4) Refractions and visual aids.
-
(5) A separate payment for pre-operative care, if provided on the day before or the day of surgery, or for typical post-operative follow-up care.
-
(6) Reversal of sterilization procedures for the purposes of conception.
-
(7) Non therapeutic hysterectomies. Therapeutic hysterectomies require that the following information to be attached to the claim:
-
(A) a copy of an acceptable acknowledgment form signed by the patient, or,
-
(B) an acknowledgment by the physician that the patient has already been rendered sterile, or,
-
(C) a physician's certification that the hysterectomy was performed under a life-threatening emergency situation.
-
(8) Induced abortions, except when certified in writing by a physician that the abortion was necessary due to a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed, or that the pregnancy is the result of an act of rape or incest.
-
(9) Medical services considered to be experimental.
-
(10) Services of a Certified Surgical Assistant.
-
(11) Services of a Chiropractor. Payment is made for Chiropractor services on Crossover claims for coinsurance and/or deductible only.
-
(12) Services of an independent licensed Physical Therapist.
-
(13) Services of a Psychologist.
-
(14) Services of an independent licensed Speech and Hearing Therapist.
-
(15) Payment for more than four outpatient visits per month (home, office, outpatient hospital) per patient, except those visits in connection with family planning or emergency medical condition.
-
(16) Payment for more than two nursing home visits per month.
-
(17) More than one inpatient visit per day per physician.
-
(18) Payment for removal of benign skin lesions unless medically necessary.