(a) Payment eligibility. To be eligible for payment as a laboratory/pathology service, the service must be:
- (1) Ordered and provided by or under the direction of a physician or other licensed practitioner within the scope of practice as defined by state law;
- (2) Provided in a hospital, physician, or independent laboratory;
- (3) Directly related to the diagnosis and treatment of a medical condition;
- (4) Authorized under the laboratory's Clinical Laboratory Improvement Amendment of 1988 (CLIA) certification; and
- (5) Considered medically necessary as defined in Oklahoma Administrative Code 317:30-3-1(f) and 317:30-5-100.
(b) Payment for inpatient/outpatient services. Payment is made to laboratories for medically necessary services to children and adults as follows:
(1) Inpatient services.
- (A) Claims for inpatient anatomical pathology must be billed by the individual pathologist performing the examination.
- (B) Inpatient consultations by pathologists are compensable. Claim form must include referring physician, diagnosis, and test(s) for which the consultation was requested.
(2) Outpatient services.
- (A) For children, payment is made for medically necessary outpatient clinical laboratory services which are provided in conjunction with physician office visits that are compensable under EPSDT.
- (B) For adults, payment is made for medically necessary outpatient services.
- (c) Payment rates. Payment will be made for covered laboratory services in accordance with methodology approved under the Oklahoma Medicaid State Plan.
- (d) Vocational rehabilitation. Payment for laboratory services is made for those vocational rehabilitation services which are preauthorized by the member's counselor.
- (e) Individuals eligible for Part B of Medicare. Payment is made utilizing the Medicaid allowable for comparable services.
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency)
Added at 12 Ok Reg 3131, eff 7-27-95
Amended at 40 Ok Reg 2197, eff 9-11-23