(a) Enhanced services. Enhanced services are available for pregnant women eligible for SoonerCare and are in addition to services for uncomplicated maternity cases. Women deemed high risk based on criteria established by the OHCA may receive prior authorization for medically necessary enhanced benefits which include:
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(1) prenatal at risk ante partum management;
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(2) a combined maximum of 12 fetal non stress test(s) and biophysical profiles (additional units can be prior authorized for multiple fetuses); and
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(3) a maximum of 6 repeat ultrasounds not covered under OAC 317:30-5-22(b)(2).
(b) Prior authorization. To receive enhanced services, the following documentation must be received by the OHCA Medical Authorizations Unit for review and approval:
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(1) ACOG or other comparable comprehensive prenatal assessment;
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(2) chart note identifying and detailing the qualifying high risk condition; and
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(3) an OHCA High Risk OB Treatment Plan/Prior Authorization Request (CH-17) signed by a Maternal Fetal Medicine (MFM) specialist.
(c) Reimbursement. When prior authorized, enhanced benefits will be reimbursed as follows:
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(1) Ante partum management for high risk is reimbursed to the primary obstetrical provider. If the primary provider of obstetrical care is not the MFM and wishes to request authorization of the ante partum management fee, the OHCA CH-17 must be signed by the primary provider of OB care. Additionally, reimbursement for enhanced at risk ante partum management is not made during an in-patient hospital stay.
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(2) Non stress tests, biophysical profiles and ultrasounds (in addition to those covered under OAC 317:30-5-22(a)(2) subparagraphs (A) through (C) are reimbursed when prior authorized.
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(3) Reimbursement for enhanced at risk ante partum management is not available to physicians who already qualify for enhanced reimbursement as state employed physicians.