OHCA Policies and Rules

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317:30-5-47.7 Rapid whole genome sequencing; inpatient hospitals

(a) Coverage. Rapid whole genome sequencing is covered for members who meet the following criteria. This service includes testing for the member and one or two biological parents.

(1) The member is under 21 years of age; 

(2) The member has a complex or acute illness of unknown etiology, that is not confirmed to be an environmental exposure, toxic ingestion, infection with normal response to therapy, or trauma; and 

(3) The member is receiving inpatient hospital services in an intensive care unit or other high acuity unit.

(b) Billing. Rapid whole genome sequencing must be billed on an outpatient claim. All rapid whole genome sequencing, including any parental testing, must be performed on behalf of a member who meets the criteria in (a) and should be filled under that member’s SoonerCare member ID number. 

(c) Reimbursement. Rapid whole genome sequencing may be reimbursed separately from the DRG pursuant to the Oklahoma Medicaid State Plan for members receiving services at an inpatient hospital. Services will be reimbursed according to the APC fee schedule.

(d) Out-of-state hospitals. Rapid whole genome sequencing provided to eligible members, when treated in out-of-state inpatient hospitals, may be reimbursed in the same manner as in-state hospitals. Out-of-state inpatient hospitals must meet applicable out-of-state conditions of payment set forth in OAC 317:30-3-89 through 317:30-3-92, and in the Oklahoma Medicaid State Plan.