Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
 

Rate Reimbursement Sheet 

 

 

ADvantage Medicaid Waiver Services
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Case Management - Standard15 minutes$13.75T1016--
Transitional Case Management - Standard15 minutes13.75T1016U3-
Case Management - Very Rural15 minutes19.69T1016TN-
Transitional Case Management – Very Rural15 minutes19.69T1016TNU3
ADvantage Personal Care15 minutes 3.78T1019--
Advanced Supportive/Restorative15 minutes 4.07T1019TF-
Registered Nurse (RN only) Skilled Nursing – Home Health Setting15 minutes13.50G0299--
Registered Nurse (RN only) Skilled Nursing – Extended State Plan Skilled Nursing15 minutes13.50G0299TF-
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) – Home Health Setting15 minutes13.50G0300--
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) - Extended State Plan Skilled Nursing15 minutes13.50G0300TF-
RN Assessment/Evaluation15 minutes13.50T1002--
Occupational Therapy15 minutes20.00G0152--
Physical Therapy15 minutes20.00G0151--
Adult Day Health15 minutes 1.88S5100U1-
Adult Day Health – Personal Care1 session/day7.50S5105--
Adult Day Health - Therapy1 session/day10.50S5105TG-
Adult Day Health – Laundry Service1 session/day7.50S5105U1-
Home Delivered Meals1 meal 4.88S5170--
Respite – Nursing Facility Extended (8+ hours)1 dayAs BilledUB120--
Respite – In-Home (2-7 hours)15 minutes 3.78T1005--
Respite – In-Home Extended (8+ hours)1 day 160.77 S9125--
Environmental ModificationsAs BilledAs BilledS5165--
Hospice1 day119.10S9126--
Specialized Medical Equipment and SuppliesAs BilledAs Prior Authorizedvarious HCPCS--
Prescriptions (maximum of  7 prescriptions per month)As Ordered76.40 eachW1111--
Additional prescriptions available through Sooner Care. For assistance, contact the Sooner Care Helpline at 1-800-987-7767

 

 

Assisted Living Services
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Standard Care LevelPer day$44.01T2031--
Intermediate Care LevelPer day$59.40T2031TF-
High Care LevelPer day$83.09T2031TG-

 

 

Incontinence Supplies

 

Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Adult Small BriefEach$0.78T4521--
Adult Medium BriefEach$0.85T4522--
Adult Large BriefEach$0.96T4523--
Adult Extra Large BriefEach$1.13T4524--
Adult Small UnderwearEach$0.86T4525--
Adult Medium UnderwearEach$1.01T4526--
Adult Large UnderwearEach$1.10T4527--
Adult Extra Large UnderwearEach$1.25T4528--
Disposable Guard/LinerEach$0.59T4535--
Any Size Reusable UnderpadEach$13.50T4537--
Chair Size Reusable UnderpadEach$14.40T4540--
Large Disposable UnderpadEach$0.58T4541--
Small Disposable UnderpadEach$0.38T4542--
Disposable Incontinence product, brief/diaper, bariatricEachAs BilledT4543--

 

Medicaid State Plan Personal Care Program
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Prescriptions (maximum of 6 prescriptions per month) As OrderedAvg $76.40S1111-
Personal Care 15 minutes$ 3.78T1019-
Individual Provider Personal Care 15 minutes$ 2.15T1019-
Skilled Nursing15 minutes$13.50S9999-

 

Medicare
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Medicare Part D PrescriptionsAs OrderedAvg $76.40 eachM1111--

 

Last Updated: August 16, 2017