Oklahoma Medicaid reimbursement rates for physician services sit at roughly parity with Medicare, with the Oklahoma Health Care Authority (OHCA) paying about 1.01 times the Medicare fee for the same services in 2024. That headline number covers only fee-for-service physician payments, though. Hospitals are paid by diagnosis-related group, nursing facilities by daily rate, and most SoonerCare members now receive care through managed care plans whose contracted rates differ from the state’s fee schedule and are supplemented by directed payment programs.
How SoonerCare Rates Compare to Medicare
KFF’s Medicaid-to-Medicare Fee Index put Oklahoma’s 2024 physician fees at approximately 1.01 relative to Medicare, above the national median. That figure captures fee-for-service payments only. It does not include the supplemental and directed payments that flow through the managed care system, which can push effective compensation higher for certain provider categories.
OHCA does not set rates in isolation. Federal law requires Medicaid payments to be sufficient to attract enough providers that patients have access comparable to the general population.1Social Security Administration. Social Security Act 1902 – State Plans for Medical Assistance Any material change to a payment methodology must be filed with the Centers for Medicare & Medicaid Services (CMS) as a State Plan Amendment and approved before it takes effect.2Centers for Medicare & Medicaid Services (CMS). Oklahoma State Plan Amendment OK-25-0018 Rates are anchored to Medicare, provider cost data, or a combination, and OHCA reviews utilization and participation periodically to decide whether adjustments are warranted.
Payment by Service Type
Inpatient Hospitals
Hospital admissions are reimbursed under a Diagnosis-Related Group (DRG) system. Each stay is assigned a DRG based on diagnosis and treatment complexity, and the hospital receives a fixed payment for that group. The hospital is paid the lesser of its billed charges or the DRG amount. An outlier payment applies when the cost of an unusually expensive stay exceeds a threshold. New hospitals joining SoonerCare receive a peer group base rate until they have enough cost history to calculate their own.3Oklahoma Health Care Authority. Reimbursement for Inpatient Hospital Services
Physician and Outpatient Services
Physicians are paid from a fee schedule that lists a maximum allowable amount for each procedure code. Payment is the lesser of the billed charge or the fee schedule amount. Pharmacy reimbursement follows its own methodology, and managed care plans must match the fee-for-service pharmacy rate unless a provider signs an alternative payment agreement.4Justia. Oklahoma Statutes Title 56 – 4002.12 Minimum Rates of Reimbursement – Value-Based Payment Arrangements The current fee schedules are posted through the OHCA provider portal.
Nursing Facilities
Long-term care facilities are paid a per diem rate, meaning a set amount per patient per day rather than payment for each individual service. As of July 2025, the base rate for a regular nursing facility is $159.56 per patient day. Facilities serving patients with AIDS receive a base rate of $290.07 per patient day. Rates account for facility type, quality rating, and nursing staffing pattern.5Legal Information Institute (LII). Oklahoma Admin Code 317:30-5-131 – Rates of Payments Allowable costs cover routine care and quality-of-care assessment fees, with the specifics set by administrative rule.6Cornell Law School. Oklahoma Admin Code 317:30-5-132.2 – Allowable Costs
Telehealth
Since November 2021, Oklahoma law has required that medically appropriate telehealth visits be reimbursed at the same rate as equivalent in-person visits. Senate Bill 674, signed in May 2021, made permanent the parity that had been in place during the COVID-19 emergency.7Oklahoma Senate. Measure Providing Telehealth Parity Signed Into Law
Maternity Care
Obstetrical care uses a bundled global payment. A physician who provides care across more than one trimester bills a single total OB care code that covers routine prenatal visits, ultrasounds performed by the attending physician, labor induction, fetal stress tests, and delivery. Minor medical problems during the prenatal period are included in the bundle. Only major illnesses clearly unrelated to the pregnancy can be billed separately.8Legal Information Institute (LII). Oklahoma Admin Code 317:30-5-22 – Obstetrical Care
Out-of-State Providers
Providers outside Oklahoma are paid the lesser of the SoonerCare fee schedule amount or their actual charge, and reimbursement generally cannot exceed the Medicare rate for the same service unless the State Plan authorizes a higher amount.9Legal Information Institute (LII). Oklahoma Admin Code 317:30-3-91 – Reimbursement of Services Rendered by Out-of-State Providers
Managed Care Rates Under SoonerSelect
On April 1, 2024, OHCA moved more than half of SoonerCare members from traditional fee-for-service into managed care under SoonerSelect. Three health plans handle medical services: Aetna Better Health of Oklahoma, Humana Healthy Horizons in Oklahoma, and Oklahoma Complete Health. Liberty Dental and DentaQuest handle dental benefits separately.10Oklahoma Health Care Authority. SoonerSelect Health Plans Launch Apr 1 – What Members Need to Know
Under managed care, the MCOs negotiate their own rates with providers. To keep those rates from dropping to the point that providers leave the network, Oklahoma requires the plans to make additional state-directed payments (SDPs) on top of the base negotiated rate.
Provider Incentive Directed Payment
Created by Senate Bill 1396 in 2022, this program funded a pool of $134.3 million for its initial 15-month period. Physicians and practitioners receive two kinds of payments. The first is a $25 add-on for specific high-value services such as preventive well visits, after-hours care, and behavioral health screenings. The second is a percentage increase applied to all covered services, estimated at roughly 19% for providers not connected to the state’s Health Information Exchange (HIE) and about 28% for HIE-connected providers.11Oklahoma.gov. Provider Incentive Directed Payment Program The higher rate for HIE-connected providers is meant to encourage data sharing.
Academic Medical Centers
Physicians affiliated with academic medical centers have a separate directed payment arrangement that targets total compensation at 175% of the Medicare fee schedule. Without the directed payment, MCOs were paying these providers an average of about 46% of Medicare. The SDP adds roughly 40 percentage points on top of that, bringing total payment to approximately 86% of Medicare for the initial rating period.12Centers for Medicare & Medicaid Services. Oklahoma Delivery System and Provider Payment Initiatives Under Medicaid Managed Care – Academic Medical Center The distance between 86% and the 175% target reflects what remains to be phased in.
Behavioral Health Value-Based Payments
Community Mental Health Centers participate in the Enhanced Tier Payment System, a value-based program that ties reimbursement to twelve quality measures. Centers that hit benchmarks receive their full share of a funding pool distributed based on client volume. Those exceeding benchmarks by a wide margin receive bonus payments from unallocated funds. Providers falling slightly below benchmarks get half payment on that measure, and those well below get nothing.13Centers for Medicare & Medicaid Services. Oklahoma Delivery System and Provider Payment Initiatives – Value-Based Payment Two of the twelve measures use secret-shopper calls that test how quickly a new patient can get seen, with the top score going to centers that schedule a screening within three days.
Billing Rules That Determine Whether You Get Paid
SoonerCare claims use standard Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. CMS requires that all Medicaid fee-for-service claims be submitted and adjudicated using these coding systems.14Centers for Medicare & Medicaid Services. Medicaid NCCI Technical Guidance Manual Modifiers attached to procedure codes flag variations like bilateral procedures or a separately identifiable evaluation performed on the same day as another service. Coding errors are one of the most common reasons claims are denied or paid at the wrong amount.
Providers have six months from the date of service to file a claim for SoonerCare reimbursement. Miss that window and payment is forfeited under state rules, with no exceptions. Federal regulations allow up to 12 months, but Oklahoma’s tighter deadline is the one that governs. There is one important carve-out: if a claim was first submitted to Medicare, the provider has 90 days after receiving Medicare’s decision to file the corresponding SoonerCare claim.15Legal Information Institute (LII). Oklahoma Admin Code 317:30-3-11 – Timely Filing Limitation A previously denied claim serves as proof of timely filing if a provider needs to resubmit.
Some services require prior authorization. Retroactive authorization is difficult to obtain, so the fee schedule and service-specific rules should be checked through the OHCA provider portal before care is delivered.
Interest When a Plan Pays Late
SoonerSelect managed care plans must process clean claims within set timeframes. When they miss the deadline, the plan owes simple interest at 1.5% per month on the unpaid clean claim until it is resolved.16Oklahoma Health Care Authority. Claims Processing and Methodology – Post-Payment Audits That works out to an 18% annual rate. Interest accrues automatically, and the plan is obligated to pay it without the provider filing a separate claim, so any provider seeing consistent payment delays should keep careful records of submission and payment dates.
Challenging a Denial or Underpayment
Providers who believe a claim was wrongly denied or underpaid can file a reconsideration request with OHCA within 30 days of the date OHCA sends written notice of the decision. Supporting documentation such as medical records and coding justifications can be added, and the decision-maker considers all submitted material regardless of whether it was in the original file.17Legal Information Institute (LII). Oklahoma Admin Code 317:2-3-5 – Member Appeals
If reconsideration does not resolve the dispute, the next step is an administrative appeal before an OHCA administrative law judge. These hearings cover program integrity audit findings, long-term care cost report adjustments, and supplemental payment disputes among other issues.18Oklahoma Health Care Authority. OHCA Policies and Rules – Appeals A favorable ruling results in a reimbursement adjustment. An unfavorable one can be appealed to an Oklahoma district court.