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Population Care Management (PCM) Programs and Services

What is Care Management?

Care management is a free program for members who have complex care coordination needs. This just means you have complicated health conditions and need many different services and appointments.

How Your Care Manager Helps

A care manager is a health care professional who acts as your partner. They work closely with your primary care provider (PCP) — your main doctor — and you to:

  • Coordinate Services: They help schedule appointments and make sure you see the right specialists and get necessary tests.
  • Organize Support: They help make sure you have follow-up care and support after a hospital stay or major illness.

Think of your care manager as a guide who helps you navigate and organize all of your doctors and services.

Extra Support for Your Pregnancy

If your pregnancy is considered high-risk, you can get extra help and benefits through our special program.

1. Starting the Program

  • Your obstetrics (OB) provider is the doctor, midwife or nurse who handles your pregnancy. They will let the insurance company know that you qualify for the high-risk OB (HROB) program. They do this through a prior authorization process, which is just a formal request for approval.

2. Receiving Benefits

  • Once the insurance company approves the request, you automatically get an enhanced HROB benefit package. This means you receive more services and benefits than a standard plan.

You will be connected with a nurse care manager (a registered nurse who specializes in pregnancy). This nurse will check in with you regularly and follow up throughout your entire pregnancy to make sure you are doing well and getting the care you need.

3. Help for Your Baby

  • The program also helps you get access to resources and services for your new baby after they are born. This includes things like:
    • Connecting you with support groups.
    • Finding specialists if your baby needs them.
    • Assistance with getting necessary follow-up care.

In short: If your pregnancy needs extra care, we connect you with a specialist nurse and extra services to support both you and your baby.

Prior Authorization Criteria

How to Get Into the OB Care Management Program

This program is for pregnant members who need extra support to prevent them from having their baby too early (pre-term labor).

1. How We Find You

  • We may reach out to you if we see that you have been prescribed certain medications that are used when a member has had a history of pre-term labor. Pre-term labor is when a baby is born before completing 37 weeks of pregnancy.

2. You Can Request it Directly

  • You (the member) or your provider (doctor, midwife, etc.) can ask to be enrolled in the OB Care Management Program directly.

To do this, simply call the Population Care Management Department at 877-252-6002.

In short: If you are at risk of having your baby early, you can be automatically enrolled or you can call 877-252-6002 to sign up for extra care.

Private Duty Nursing Care Management (PDN) is a special program that helps children with serious, complex health needs get the nursing care they need at home.

What is PDN?

  • It is medically necessary care. This means a doctor has determined your child needs it.
  • The care is provided regularly by a licensed nurse (either an LPN or an RN).

Who Qualifies for PDN?

This benefit is for SoonerCare children who:

  • Are under age 21.
  • Have complex special health care needs that require regular nursing support.
  • Need an alternative to staying in a hospital or institution (they can receive this high-level care at home in the community).

How Does a Child Get Approved?

  • Request for Services: Your child's care provider sends in an initial request for PDN services.
  • Assessment: A population nurse care manager will meet with your child (either in person or by phone/video) to do a detailed health assessment.
  • Final Decision: A doctor in the Medical Professional Services Unit uses the nurse's assessment to decide if your child qualifies for PDN. This is called the medical authorization process.

Ongoing Support

  • Periodic Check-ins: Once approved, the nurse care manager will continue to do check-ins and reassessments (in person or by phone/video) to make sure your child continues to qualify and is getting the right amount of PDN care.
  • Care Management: The nurse care manager also provides helpful care management support to coordinate your child's overall health needs.

Authorization Criteria and Applying for Prior Authorization

The Paid Family Caregiver (PFC) program allows a trained family member to be paid to provide some of the necessary care for a child who qualifies for private duty nursing (PDN).

Why Was This Program Created?

The PFC program addresses a major staffing challenge. Not enough nurses are available, especially in smaller towns (rural areas), to provide the necessary in-home care. This benefit will be available March 1, 2026.

  • The Goal: It allows a safe, trained family member to provide care instead of a nurse for certain tasks.
  • Preventing Hard Choices: This option helps families stay together and avoid difficult decisions like:
    • Giving up their jobs.
    • Losing their housing.
    • In extreme cases, having to give up custody of their child to the state.

Who Qualifies for PFC?

The child must:

  • Be ages 0–20.
  • Already be approved for private duty nursing (PDN) services through SoonerCare.
  • Have complex special health care needs that require in-home care.

What Care Can a Family Member Provide?

  • A qualifying child can receive up to 40 hours per week of care provided by a trained paid family caregiver.
  • The family caregiver provides care that can be safely delivered without a nurse.

Who Can Be a Paid Family Caregiver?

A family member can be:

  • A parent, grandparent, sibling, child, grandchild or spouse.
  • A parent-in-law or other individual related by blood.
  • Any other individual with a close relationship that is like a family relationship.

How Does It Help?

  • Better Access to Care: It ensures children with the most complex needs get the reliable care they require.
  • Nurse Availability: By having a family member provide some of the care, it frees up nurses to provide other essential personal care services for other children who need them.

How to Get Approved

Your child must go through the same medical authorization process to be approved for both the Private Duty Nursing and Paid Family Caregiver programs.

Authorization Criteria and Applying for the Prior Authorization

Getting Care Outside of Oklahoma

This information explains the rules for getting approval to receive medical services outside of Oklahoma.

1. Our Goal

We use these guidelines to make sure that:

  • The requested medical services are medically necessary (meaning they are truly needed for your health).
  • The process for approving or denying care is consistent (meaning everyone is treated fairly).

2. When You Need Approval (Prior Authorization)

The Oklahoma Health Care Authority has a program for services received out of state (outside of Oklahoma).

  • You need a prior authorization (PA) — a formal approval from us — for any service that is not an emergency and happens more than 50 miles away from the Oklahoma state line.
    • Example: If you need a planned surgery in Dallas, Texas, which is more than 50 miles away, your doctor must get a PA first.

3. Extra Help for Complex Cases

The same process that approves care out of state also provides an extra benefit: case management.

  • If you need a service that is medically necessary but not available in Oklahoma, we will assign a case manager to work with you.
  • This case manager helps you coordinate your care, set up appointments, and manage the logistics of getting these necessary services outside the state.

In short: If you need non-emergency care more than 50 miles outside of Oklahoma, your doctor must get approval first. This process also connects you with a case manager if you need specialized care only offered out of state.

Authorization Criteria and Applying for Prior Authorization

Rule Changes - SoonerCare Out-of-State Services Rule Changes

Ambulance Transportation Coverage

The Population Care Management team reviews requests for scheduled ambulance trips (both ground and air) to see if they are covered by your plan.

When is an Ambulance Covered?

SoonerCare covers scheduled ambulance trips only when they are medically necessary. This means:

  • Your health condition makes it unsafe for you to travel any other way (such as by car, van or bus).
  • You are being moved to the nearest hospital or facility that can give you the care you need.

How to Get Approval

Before your trip, we must perform a prior authorization (a formal review for approval). To help SoonerCare Population Care Management decide, your doctor must provide:

  • Medical Records: Notes from your doctor explaining your medical condition.
  • Reason for Transport: Documentation showing why other types of transportation would be unsafe for you.

Authorization Criteria and Applying for the Prior Authorization

Help for Breast and Cervical Cancer Treatment

This program offers SoonerCare (Oklahoma's Medicaid program) benefits to qualifying women who need diagnosis and treatment for breast and/or cervical cancer.

The Program

This is a partnership between several groups in Oklahoma to make sure women get the care they need:

  • Oklahoma Health Care Authority (OHCA)
  • Oklahoma State Department of Health
  • Cherokee Nation
  • Kaw Nation

How to Qualify

To get into this program, you must meet certain medical and financial rules:

  • Medical Criteria: You must have been screened for breast or cervical cancer (or pre-cancer) and found to be in need of treatment.
  • Financial Criteria: You must meet the program's income guidelines and not have other insurance that covers the treatment for these cancers.

How to Apply

You cannot start the application yourself. It must be started by a certified screener (a health care provider who has been approved to enroll people in this program).

To find a certified screener or to get more information, please call one of the organizations below:

  • Oklahoma State Department of Health at 866-550-5585
  • Cherokee Nation at 800-256-0671 ext. 5442 or 918-453-5442
  • Kaw Nation at 580-362-1039 ext. 229

How You Get Help After Applying

Next steps once your certified screener sends in your application.

  • Nurse Review: Nurse care managers at the Population Care Management department review the application to confirm you meet the medical criteria.
  • Ongoing Support: If approved, a care manager will work with you throughout your time in the program to help coordinate your treatment and services.

In short: If you need treatment for breast or cervical cancer and meet the requirements, this program gives you full SoonerCare benefits. Call the numbers above to find a certified screener who can help you apply.

Last Modified on Feb 04, 2026