Oklahoma – EPSDT

In Oklahoma :
  • As of July 1, 2011, there were 684,387 individuals enrolled in the state’s Medicaid program, SoonerCare; 591,850 of these individuals were enrolled in a prepaid ambulatory health plan (PAHP) that provides transportation benefits.
  • 439,228 Medicaid enrollees receive physical, behavioral, and dental services through the state’s primary care case management (PCCM) program, known as SoonerCare Choice. Medicaid beneficiaries who reside in an institution, receive home- and community-based waiver services, qualify for Medicare, or who are in an HMO are not eligible for SoonerCare Choice.
  • Children with special health care needs may be eligible for one of the state’s several waiver programs, including:
As of 2013, 612,081 individuals were eligible for Oklahoma’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known as Child Health Check Up. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 75% and a participant ratio of 56%. 273,832 children received dental services of any kind, with 250,817 receiving preventive dental services.
Last updated September 2014
Medical Necessity
According to the Medicaid rules of the Oklahoma Health Care Authority, the following standards are considered when determining medical necessity:
  1. Services must be medical in nature and must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability;
  2. Documentation submitted in order to request services or substantiate previously provided services must demonstrate through adequate objective medical records, evidence sufficient to justify the client’s need for the service;
  3. Treatment of the client’s condition, disease or injury must be based on reasonable and predictable health outcomes;
  4. Services must be necessary to alleviate a medical condition and must be required for reasons other than convenience for the client, family, or medical provider;
  5. Services must be delivered in the most cost-effective manner and most appropriate setting; and
  6. Services must be appropriate for the client’s age and health status and developed for the client to achieve, maintain or promote functional capacity.
Further, the Oklahoma EPSDT Provider Manual states “1905(a) services, deemed medically necessary and allowable under federal and Medicaid regulations, must be covered by the OHCA Child Health Checkup (EPSDT) program even though those services may not be part of the Medicaid State Plan. However, such services may require a prior authorization and must be allowable under federal or Medicaid regulations.”
Initiatives to Improve Access
SoonerExcel: EPSDT Incentive Payments
As part of the Oklahoma Medicaid agency’s incentive program, SoonerExcel, the state pays an EPSDT incentive bonus to primary care providers (PCPs) in order to increase compliance with and access to initial and periodic screening services. A total pool of $1 million is made available to PCPs that meet or exceed the EPSDT compliance rate for medical home members; qualifying PCPs receive an additional 25% of the rate for the age appropriate procedure code according to the fee schedule.
The SoonerExcel program also rewards providers who immunize a child with the 4th DTaP prior to age 2. PCPs who achieve this goal are eligible to receive $3.00 per child, depending on available funding.
Oklahoma EPSDT staff work with the Department of Education and the Department of Health to increase access to services for SoonerCare members through school-based and early intervention services. School districts may contract with the state Medicaid agency to seek reimbursement for medically necessary services provided to SoonerCare members in accordance with the Individuals Disability Education Act. Services include speech therapy/evaluation, occupational therapy/evaluation, hearing and vision services, nursing services, and psychological services.
Reporting & Data Collection
HEDIS measures
The Oklahoma Medicaid agency reports on several HEDIS measures relating to EPSDT, including:
  • Child Health Checkups (Ages 0-15 months, 3-6 years, Adolescents)
  • Children’s Access to PCP (Ages 12-24 months, 25 months-6 years, 7-11 years, 12-19 years);
  • Lead Screening in Children;
  • Appropriate Medications for the Treatment of Asthma;
  • Appropriate Testing for Children with Pharyngitis; and
  • Appropriate Testing for Children with Upper Respiratory Infection.
Provider Profiles
SoonerCare Choice providers receive Child Health Checkup provider profiles on a bi-annual basis. These profiles offer providers feedback to help them evaluate their performance compared to their peers, and contain information on the number of children on their panel for any part of a one-year review period and the number of Child Health Checkup screenings conducted during that period.
Behavioral Health
SoonerCare Choice medical home providers are required to complete a behavioral health screening on an annual basis for all children ages 5 and above. To assist with these screenings, the Oklahoma Medicaid Agency developed a 1 page pediatric screening tool and a behavioral health toolkit.
Providers completing medical home self evaluations for all three tiers of patient-centered medical home in Oklahoma must indicate that:
“During annual visits PROVIDER uses behavioral screening, brief intervention, and referral to treatment for members 5 and above. Through the use of these screening tools the provider will expedite treatment for members with positive screens with the goal of improving outcomes for members with mental health and/or alcohol or substance use disorders. “
Support to Providers and Families
Support to Providers
Information for providers on the Oklahoma EPSDT program can be found in the Child Health Checkup Provider Manual, which includes a program overview, billing codes, prior authorization processes, and periodicity schedules. Periodicity schedules and providers forms are also available on the Child Health Unit web page.
The state Medicaid agency operates a provider portal, which allows providers to access claims and prior authorization data, and receive messages from the Oklahoma Health Care Authority.
Support to Families
Resources for families are available through the SoonerCare Choice member handbook and the Child Health Checkups brochure for parents. A provider directory is also available to help families locate participating Medicaid providers.
Care Coordination
Medical Homes
Providers participating in SoonerCare Choice, Oklahoma’s primary care case management program, serve as an individual’s “medical home.” Care coordination services provided through the medical home include coordinating and monitoring all medical care for members; specialty referrals; coordinating hospital admissions; referrals to the Women, Infants, and Children (WIC) program; coordinating with mental health services; and patient education.
Medicaid beneficiaries in the Tulsa region may also receive medical home services and coordinated care through the state’s Comprehensive Primary Care Initiative, which brings together state, federal, and commercial payers to strengthen primary care.
For more information on Oklahoma’s medical home initiatives, visit the NASHP medical homes map page.
Oral Health
Oklahoma Medicaid operates a dental services page that provides information on the importance of dental health, an FAQ, and a dental provider directory. Information on dental prior authorization, screening services, and dental reminder periodicity schedule is available in the Child Health Checkup Provider Manual.

– See more at: http://nashp.org/epsdt/Oklahoma#sthash.RGe7Lmlo.dpuf