MEDICAL PRIOR
AUTHORIZATIONS
May 2022
2 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
The information contained in this presentation is intended
to instruct SoonerCare providers on the prior authorization
process for medical services, with member and procedure
verification steps and a demonstration of a prior
authorization submission using the secure provider portal.
NOTE: does not contain information on submitting
authorization using InterQual. View the Medical
Authorization Using InterQual presentation.
3 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
DISCLAIMER
SoonerCare policy is subject to change. The information
included in this presentation is current as of May 2022. The
most current information can be found on the OHCA
public website at www.oklahoma.gov/ohca.
4 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
AGENDA
Notes on Prior Authorization
Verification
-Eligibility Verification
-Treatment History
-Fee Schedule
Prior Authorization Submission
Amendments
Resources
NOTES ON
PRIOR
AUTHORIZATION
6 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Under the SoonerCare program, there are services that
require prior authorization (PA) by the Oklahoma Health
Care Authority (OHCA).
• Represents a clinical decision regarding medical necessity.
• PA approval is not a guarantee of member eligibility or
SoonerCare payment.
OHCA’s Medical Authorization Unit (MAU) webpage provides a list of
medical, DME and supplies, therapy and out-of-state services that
require PA and the guidelines for each service.
7 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• Requests processed by the MAU such as durable
medical equipment (DME), high tech imaging,
medical procedures and supplies, or
occupational/physical/speech must be submitted
electronically through the SoonerCare provider
portal.
• ALL drug prior authorization requests (PARs) are
processed through the Pharmacy PA Unit
whether the drug is billed on a medical claim or by
a pharmacy. Drug PA criteria and forms can be
found at www.oklahoma.gov/ohca/pa.
• PARs that do not require a servicing provider are
issued to the member, allowing both a provider
and a facility to be paid using a single PA.
• If the member does not have program eligibility
for the “from date” of service, the PAR will system
cancel.
8 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• If a member’s eligibility has been backdated, the
PAR entered on the portal will system cancel as a
retro authorization. The provider should submit an
email to MAUAdmin@okhca.org with the subject
line “Retro Eligibility – please review” to request a
case-by-case review.
• For continuation of approved services, a new PAR
with documentation must be submitted.
• Approved dates of service on a PAR cannot
overlap the date of service on another PAR for the
same service.
• An emergent or urgent PAR will be considered for
loss of life or limb. Providers should submit the
PAR via the portal and an email to
MAUAdmin@okcha.org with “Emergency PA” in
the subject line.
9 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
AUTHORIZATIONS BY UNIT
Medical Authorizations
:
800
-522-0114, option 6, 3 or
MAUadmin@okhca.org
Pharmacy Help Desk
:
800
-522-0114, option 6, 1 or
Fax 405
-271-4014
Dental Authorizations
:
405
-522-7401
Occupation/Physical/Speech Therapy:
Therapyadmin@okhca.org
Durable Medical Equipment
:
DMEadmin@okhca.org
Personal Care
:
Contact local DHS office
PASRR Level of Care Unit
:
405
-522-7597 & 405-522-7674
Advantage Administration Unit
:
918
-933-4900
Developmental Disabilities Services
Division (DDSD)
:
800
-349-9173 or Fax 405-573-6853
Medically Fragile Waiver
:
888
-287-2443
Behavioral Health Inpatient
:
800
-522-0114, option 6, 2, 2
Behavioral Health Outpatient
:
800
-522-0114, option 6, 2, 1
VERIFICATION
11 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Before submitting a prior authorization request,
providers should verify the following:
____ The member has SoonerCare eligibility.
____ The member’s limit for the procedure has not been
reached.
____ The procedure is covered and requires prior
authorization.
12 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
MEMBER ELIGIBILITY
The member’s
eligibility must
include either Title
19 or Expansion
Healthy Adult
Program for active
SoonerCare
benefits.
13 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
TREATMENT HISTORY
The Treatment
History feature
allows users to
retrieve paid claim
records for a
particular member
so a provider can see
how many units
have already been
paid during a
particular timeframe.
14 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
SEARCH FEE SCHEDULE
Search Fee Schedule will
indicate if the procedure is
covered under the selected
Benefit Package and if it
requires prior authorization.
PRIOR
AUTHORIZATION
SUBMISSION
16 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Prior Authorization requests must be submitted online
using the OHCA secure provider portal.
17 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
18 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Only required for durable medical equipment, prosthetics,
orthotics and supplies, home health, hospice, specialized nursing and
vision care services.
All other types leave this blank.
19 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Accepted attachment file types: JPG, PDF, TIF, XPS
File size: up to 10 MB
Select Browse to locate and upload the correct file, enter a brief
Description, and Add the attachment to the authorization request.
Add Attachments how-to video
20 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Choose the appropriate Assignment Code.
21 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Enter the primary diagnosis without a decimal and Add.
Name & Phone # of PA Contact person
22 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Most PA requests must be received within 30 days of the initial date of service.
• Therapy – No retro
• Imaging – MRA, MRI, CT, PET 3-day retro
Enter up to
four modifiers,
if applicable.
Enter number of units.
Choose
appropriate
code type:
NDC,
procedure
code or
group,
revenue, or
surgical.
Enter code.
23 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
A Prior Authorization Number will be generated to confirm the
request was submitted successfully.
• This does not mean the PA is approved.
• Can be used to check status.
24 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
AMENDMENTS
26 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
AMENDMENTS
In order to streamline the amendment process, the
Medical Authorization Unit is implementing a change in
the submittal of amendment requests.
• Effective immediately providers can now submit their
amendment requests through the secure provider
portal.
• The faxed option will be discontinued and faxes for PA
amendments will no longer be accepted effective
May 1, 2022.
27 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
MORE ON AMENDMENTS
• Amendments can only be requested for a PAR in an
approved status.
• Amendments must be received within six months from
the date of service.
• HCA-60 form will be required along with documentation
to support the requested change.
• Amendments for continuation of service will not be
processed and requires a new PAR.
28 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
What can be amended:
• Dates of service
• Units
• Codes
• Provider numbers
• Modifiers
• Member recipient ID
29 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• Log into the secure
provider portal and
click on the Prior
Authorization tab at
the top.
• Click View
Authorization Status.
• Enter Prior
Authorization(PA)
Number and click
search button.
• This will bring up the
PA in Search Results
where you will click
on the PA number.
30 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• Once you have
clicked on the PA
Number it will
bring up the view
status of the PA.
• Next you will click
the View Original
Request button.
31 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Now that you have
clicked the View
Original Request
button, you will be
able to do one of the
following:
• Cancel a Line - in
Approved (with
no claims filed
against the line),
Evaluation,
Pending and
Pending
Documents
Status.
• Amend a Line –
in Approved
Status only.
32 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• Cancel – you will
click on the box in
the Cancel column
for the line(s) you
would like to
cancel, then click
on the Submit
button. This will
immediately
cancel that line
item.
• Amend – you will
click on the box in
the Amend column
for the line(s) you
would like to
amend (do not
click the Submit
button yet).
33 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• Once you have
clicked on the
Amend box for all the
lines you want to
amend, you will scroll
back up to the
Attachments section.
• Next, you will click on
the HCA-60 Form
link and complete
the form and save to
your computer.
• Now, upload the
HCA-60 form and any
other documents
that support the
requested changes.
• Select browse.
• Locate the
document(s) to
upload.
• Give the
document(s) a
description.
• Now click the Add
button to add the
documents.
B12345678 Kerry SoonerCare
34 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Once you have added the
document(s), your page
will refresh and will then
show the attachment(s)
you added. You will be
able to remove this
attachment ONLY if you
uploaded the wrong
document.
35 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
The last step in
submitting an
Amendment
request is to
click on the
Submit
button.
36 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
Once you
have clicked
the Submit
button, the
page will
refresh and
give you a
message of a
successful
submission.
Kerry SoonerCareB12345678
Doctor Medical
123456789 A
111222333
123A45678B
RESOURCES
38 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
MEDICAL AUTHORIZATION UNIT
The goal of MAU is to streamline the PAR process while
maintaining compliance with OHCA, state and federal
policy and rules.
• Call 800-522-0114, option 6, 4
• Email MAUAdmin@okhca.org
• MAU webpage
DME authorization assistance: email DMEAdmin@okhca.org.
Therapy authorization assistance: email TherapyAdmin@okhca.org.
39 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
• OHCA provider helpline.
‐ 800-522-0114 or 405-522-6205; option 1
• Internet help desk.
‐ 800-522-0114 or 405-522-6205; option 2, 1
• EDI help desk.
‐ 800-522-0114 or 405-522-6205; option 2, 2
HELPFUL TELEPHONE NUMBERS
40 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
HELPFUL LINKS
• Agency website
‐ www.oklahoma.gov/ohca
• OHCA provider portal
‐ www.ohcaprovider.com
• Provider training
‐ www.oklahoma.gov/ohca/providers/provider-training
• Provider Quick Reference Guide
• OHCA Resource Guide
41 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
OHCA PUBLIC WEBSITE
OHCA’s public website is the best source for current
SoonerCare information: www.oklahoma.gov/ohca.
• A Provider Toolkit is available to help providers locate helpful
information online more efficiently.
• Find service-specific information such as rules, manuals, prior
authorization, forms and contracts for enrolling in the SoonerCare
program and other important topics based on the services you
provide on the Provider Types page.
• Policy and rules are available to review online.
42 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
TRAINING RESOURCES
• Provider education specialists:
- Education specialists provide education and training as needed
for providers either virtually or telephonically.
- Requests for assistance should be emailed to:
SoonerCareEducation@okhca.org. (Requests should include the
provider's name and ID, contact information, and a brief
description of what assistance is being sought.)
- For immediate claims or policy assistance, please contact the
OHCA provider helpline at 800-522-0114.
• Monthly webinars
• How-to videos
QUESTIONS?
44 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105
Oklahoma.org/ohca
mysoonercare.org
Agency: 405-522-7300
Helpline: 800-987-7767
G E T I N T O U C H