Oklahoma OK

Oklahoma SoonerCare PA is a TWO-LOCUS mixed model since SoonerSelect managed-care launch 2024-04-01. (1) FFS / SoonerCare Choice (PCMH residual): authority = OHCA Medical Authorization Unit (MAU). FFS PA criteria live as OHCA-published per-service MEDICAL GUIDELINE PDFs under .../providers/claim-tools/prior-authorization/medical.html (~40 condition/procedure guidelines) PLUS licensed InterQual criteria (gated behind One Healthcare ID login). FFS requests submitted on form HCA-12A through the OHCA secure provider portal (Gainwell). Pharmacy FFS PA separate (OHCA SoonerCare PDL/PBM). (2) SoonerSelect managed care (3 medical MCOs: Aetna Better Health, Humana Healthy Horizons, Oklahoma Complete Health/Centene): each MCO publishes its OWN Prior Authorization Guide. OHCA additionally hosts 'MAC Documents' (SEL-0109 Medical Advisory Committee service-provision change docs) recording per-MCO PA add/remove decisions on specific CPT/HCPCS codes. NO single master PA code list document; pinned okhca.org/prior-authorization-codes is dead (consolidated to oklahoma.gov/ohca).

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# OK — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 30 docs. See [[state_shape_OK]]. Correction pass: OK IS one of the six WISeR-model states (AZ/NJ/OH/OK/TX/WA), so the WISeR mention is KEPT and corrected — the model said "WISeR pilot status unspecified" but did not give an expansion. WISeR = CMS's "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization demonstration (live Jan 5 2026), a Medicare-side initiative distinct from Oklahoma's SoonerCare/SoonerSelect Medicaid PA processes. Corrected below. ## 1. How OK requires PA Oklahoma's Medicaid program, SoonerCare, employs a mixed model for prior authorization (PA) requirements. This dual-layered approach involves the Oklahoma Health Care Authority (OHCA) Medical Authorization Unit (MAU) and managed-care organizations (MCOs). The MAU handles per-service guidelines through PDF documents on its website, while MCOs like Aetna Better Health of Oklahoma and Humana Healthy Horizons manage their own PA processes. Specific services requiring PA include bariatric surgery, wound care, out-of-state services, organ transplants, outpatient therapy, HAE medications, IV/SC immunoglobulins, Nyvepria, Photrexa, and certain surgical procedures. Documentation requirements vary but generally necessitate clinical documentation supporting medical necessity. ## 2. How OK publishes and reports PA Oklahoma publishes its PA criteria through various channels. The OHCA MAU provides per-service guidelines as PDFs on its website under the "providers" section, specifying criteria, CPT/HCPCS codes, effective dates, and next review dates. MCOs such as Aetna and Humana publish their own PA guides. Monthly bulletins from OHCA provide updates on PA processes, including timeliness requirements. For instance, Bulletin 2025-22 outlines expedited and standard PA processing timelines effective January 1, 2026. ## 3. OK's CMS-0057-F and PA-reform compliance posture Oklahoma's stance on CMS-0057-F is partially addressed but not comprehensively detailed in the source documents. The state has implemented some PA-decision-timeframe elements, such as setting expedited (72-hour) and standard (7-calendar-day, up to 14 for complex) PA processing timelines (Bulletin 2025-22, effective Jan 1, 2026). There is no explicit mention of formal CMS-0057-F submission in the sources. **Oklahoma is one of six states in CMS's WISeR ("Wasteful and Inappropriate Service Reduction") model** — a Medicare prior-authorization demonstration (live Jan 5, 2026; states AZ/NJ/OH/OK/TX/WA). WISeR is a Medicare-side initiative and is distinct from Oklahoma's SoonerCare/SoonerSelect Medicaid PA processes. (The local model left WISeR "unspecified" with no expansion; corrected here.) ## 4. How OK runs its own program Oklahoma's Medicaid program, SoonerCare, operates under a managed-care model (SoonerSelect MCOs) with a fee-for-service (FFS) component for certain services. The MAU oversees FFS PA guidelines, while MCOs like Aetna and Humana manage their own PA processes. The state's 1115(a) waiver, the SoonerCare Demonstration, allows flexibility in program design. Per source documents, behavioral health services are carved into MCOs, while long-term services and supports (LTSS) remain under FFS. The foster care program is managed through the SoonerSelect Children's Specialty Program (CSP). ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Dual-Layered PA System**: OHCA MAU handles per-service guidelines for FFS; MCOs manage their own PA processes. - **WISeR-model state:** OK is one of six states in CMS's Medicare WISeR PA demonstration (correct expansion: Wasteful and Inappropriate Service Reduction). - **Specific Service Guidelines**: Detailed criteria for services like bariatric surgery, organ transplants, and wound care. - **Documentation Requirements**: Consistent emphasis on clinical documentation supporting medical necessity. ### What's Missing/Uncertain: - **CMS-0057-F Compliance**: No explicit mention of formal submission in the sources. - **Gold Card Law Details**: Specifics not provided. - **Full List of MCOs and Contracts**: Procurement cycle detailed, but a comprehensive current-MCO/contract list is missing. - **Complete Documentation for All Services**: Some guidelines lack specific CPT/HCPCS codes or detailed medical-necessity criteria.

Last award: 2023-06-22. Next due: TBD — re-RFP expected before exhaustion of renewal options. Contracts extended through: 2025-06-30 base term, currently in renewal-option years; rate floor expires 2026-07-01.