Oklahoma § 36-6055 - Performance of services and procedures by practitioners Freedom of choice - Exclusions - Compensation of practitioners Decisions to authorize or deny emergency services

§ 36-6055. Performance of services and procedures by practitioners Freedom of choice - Exclusions - Compensation of practitioners Decisions to authorize or deny emergency services

A. Under any accident and health insurance policy, hereafter

renewed or issued for delivery from out of Oklahoma or in Oklahoma

by any insurer and covering an Oklahoma risk, the services and

procedures may be performed by any practitioner selected by the

insured, or the parent or guardian of the insured if the insured is

a minor, if the services and procedures fall within the licensed

scope of practice of the practitioner providing the same.

B. An accident and health insurance policy may:

1. Exclude or limit coverage for a particular illness, disease,

injury or condition; but, except for such exclusions or limits,

shall not exclude or limit particular services or procedures that

can be provided for the diagnosis and treatment of a covered

illness, disease, injury or condition, if such exclusion or

limitation has the effect of discriminating against a particular

class of practitioner. However, such services and procedures, in

order to be a covered medical expense, must:

a.

be medically necessary,

b.

be of proven efficacy, and

c.

fall within the licensed scope of practice of the

practitioner providing same; and

2. Provide for the application of deductibles and copayment

provisions, when equally applied to all covered charges for services

and procedures that can be provided by any practitioner for the

diagnosis and treatment of a covered illness, disease, injury or

condition.

C. 1. Paragraph 2 of subsection B of this section shall not be

construed to prohibit differences in cost-sharing provisions such as

deductibles and copayment provisions between practitioners,

hospitals, ambulatory surgical centers, home care agencies, or other

health care providers or facilities that are licensed or certified

by the state who are participating preferred provider organization

providers and practitioners, hospitals, ambulatory surgical centers,

home care agencies, or other health care providers or facilities

Oklahoma Statutes - Title 36. Insurance

that are licensed or certified by the state who are not

participating in the preferred provider organization, subject to the

following limitations:

a.

the amount of any annual deductible per covered person

or per family for treatment in a hospital or

ambulatory surgical center that is not a preferred

provider shall not exceed three times the amount of a

corresponding annual deductible for treatment in a

hospital or ambulatory surgical center that is a

preferred provider,

b.

if the policy has no deductible for treatment in a

preferred provider hospital or ambulatory surgical

center, the deductible for treatment in a hospital or

ambulatory surgical center that is not a preferred

provider shall not exceed One Thousand Dollars

($1,000.00) per covered-person visit,

c.

the amount of any annual deductible per covered person

or per family treatment, other than inpatient

treatment, by a practitioner that is not a preferred

practitioner shall not exceed three times the amount

of a corresponding annual deductible for treatment,

other than inpatient treatment, by a preferred

practitioner,

d.

if the policy has no deductible for treatment by a

preferred practitioner, the annual deductible for

treatment received from a practitioner that is not a

preferred practitioner shall not exceed Five Hundred

Dollars ($500.00) per covered person, and

e.

the percentage amount of any coinsurance to be paid by

an insured to a practitioner, hospital or ambulatory

surgical center that is not a preferred provider shall

not exceed by more than thirty (30) percentage points

the percentage amount of any coinsurance payment to be

paid to a preferred provider.

2. The Commissioner has discretion to approve a cost-sharing

arrangement which does not satisfy the limitations imposed by this

subsection if the Commissioner finds that such cost-sharing

arrangement will provide a reduction in premium costs.

D. 1. A practitioner, hospital, ambulatory surgical center,

home care agency, or other health care provider or facility that is

licensed or certified by the state that is not a preferred provider

shall disclose to the insured, in writing, that the insured may be

responsible for:

a.

higher coinsurance and deductibles, and

b.

practitioner, hospital or ambulatory surgical center

charges which exceed the allowable charges of a

preferred provider, and

Oklahoma Statutes - Title 36. Insurance

c.

a good-faith estimate of the total cost to the

insured.

2. When a referral is made to a nonparticipating hospital or

ambulatory surgical center, the referring practitioner must disclose

in writing to the insured, any ownership interest in the

nonparticipating hospital or ambulatory surgical center.

E. Upon submission of a claim by a practitioner, hospital, home

care agency, ambulatory surgical center, or other health care

provider or facility that is licensed or certified by the state to

an insurer on a uniform health care claim form adopted by the

Insurance Commissioner pursuant to Section 6581 of this title, the

insurer shall provide a timely explanation of benefits to the

practitioner, hospital, home care agency, ambulatory surgical

center, or other health care provider or facility that is licensed

or certified by the state regardless of the network participation

status of such person or entity.

F. Benefits available under an accident and health insurance

policy, at the option of the insured, shall be assignable to a

practitioner, hospital, home care agency, ambulatory surgical

center, or other health care provider or facility that is licensed

or certified by the state who has provided services and procedures

which are covered under the policy. A practitioner, hospital, home

care agency, ambulatory surgical center, or other health care

provider or facility that is licensed or certified by the state

shall be compensated directly by an insurer for services and

procedures which have been provided when the following conditions

are met:

1. Benefits available under a policy have been assigned in

writing by an insured to the practitioner, hospital, home care

agency, ambulatory surgical center, or other health care provider or

facility that is licensed or certified by the state;

2. A copy of the assignment has been provided by the

practitioner, hospital, home care agency, ambulatory surgical

center, or other health care provider or facility that is licensed

or certified by the state to the insurer;

3. A claim has been submitted by the practitioner, hospital,

home care agency, ambulatory surgical center, or other health care

provider or facility that is licensed or certified by the state to

the insurer on a uniform health insurance claim form adopted by the

Insurance Commissioner pursuant to Section 6581 of this title; and

4. A copy of the claim and the estimate required in

subparagraph c of paragraph 1 of subsection D of this section have

been provided by the practitioner, hospital, home care agency,

ambulatory surgical center, or other health care provider or

facility that is licensed or certified by the state to the insured.

G. The provisions of subsection F of this section shall not

apply to:

Oklahoma Statutes - Title 36. Insurance

1. Any preferred provider organization (PPO), as defined by

generally accepted industry standards, that contracts with

practitioners that agree to accept the reimbursement available under

the PPO agreement as payment in full and agree not to balance bill

the insured; or

2. Any statewide provider network which:

a.

provides that a practitioner, hospital, home care

agency, ambulatory surgical center, or other health

care provider or facility that is licensed or

certified by the state who joins the provider network

shall be compensated directly by the insurer,

b.

does not have any terms or conditions which have the

effect of discriminating against a particular class of

practitioner,

c.

allows any practitioner, hospital, home care agency,

ambulatory surgical center, or other health care

provider or facility that is licensed or certified by

the state, except a practitioner who has a prior

felony conviction, to become a network provider if the

hospital or practitioner is willing to comply with the

terms and conditions of a standard network provider

contract, and

d.

contracts with practitioners that agree to accept the

reimbursement available under the network agreement as

payment in full and agree not to balance bill the

insured.

The provisions of this section shall not be deemed to prohibit a

policyholder from assigning benefits available pursuant to an

accident and health insurance policy, provided that the benefits of

such policy include out-of-network provisions and are being assigned

to an out-of-network practitioner, hospital, home care agency,

ambulatory surgical center, or other health care provider or

facility that is licensed or certified by the state. The

assignability of an accident and health insurance policy related to

out-of-network care shall only be subject to the terms and

conditions specified in subsection F of this section.

H. A nonparticipating practitioner, hospital or ambulatory

surgical center may request from an insurer and the insurer shall

supply a good-faith estimate of the allowable fee for a procedure to

be performed upon an insured based upon information regarding the

anticipated medical needs of the insured provided to the insurer by

the nonparticipating practitioner.

I. A practitioner shall be equally compensated for covered

services and procedures provided to an insured on the basis of

charges prevailing in the same geographical area or in similar sized

communities for similar services and procedures provided to

Oklahoma Statutes - Title 36. Insurance

similarly ill or injured persons regardless of the branch of the

healing arts to which the practitioner may belong, if:

1. The practitioner does not authorize or permit false and

fraudulent advertising regarding the services and procedures

provided by the practitioner; and

2. The practitioner does not aid or abet the insured to violate

the terms of the policy.

J. Nothing in the Health Care Freedom of Choice Act shall

prohibit an insurer from establishing a preferred provider

organization and a standard participating provider contract

therefor, specifying the terms and conditions, including, but not

limited to, provider qualifications, and alternative levels or

methods of payment that must be met by a practitioner selected by

the insurer as a participating preferred provider organization

provider.

K. A preferred provider organization, in executing a contract,

shall not, by the terms and conditions of the contract or internal

protocol, discriminate within its network of practitioners with

respect to participation and reimbursement as it relates to any

practitioner who is acting within the scope of the practitioner's

license under the law solely on the basis of such license.

L. Decisions by an insurer or a preferred provider organization

(PPO) to authorize or deny coverage for an emergency service shall

be based on the patient presenting symptoms arising from any injury,

illness, or condition manifesting itself by acute symptoms of

sufficient severity, including severe pain, such that a reasonable

and prudent layperson could expect the absence of medical attention

to result in serious:

1. Jeopardy to the health of the patient;

2. Impairment of bodily function; or

3. Dysfunction of any bodily organ or part.

M. An insurer or preferred provider organization (PPO) shall

not deny an otherwise covered emergency service based solely upon

lack of notification to the insurer or PPO.

N. An insurer or a preferred provider organization (PPO) shall

compensate a provider for patient screening, evaluation, and

examination services that are reasonably calculated to assist the

provider in determining whether the condition of the patient

requires emergency service. If the provider determines that the

patient does not require emergency service, coverage for services

rendered subsequent to that determination shall be governed by the

policy or PPO contract.

O. Nothing in the Health Care Freedom of Choice Act shall be

construed as prohibiting an insurer, preferred provider organization

or other network from determining the adequacy of the size of its

network.

Oklahoma Statutes - Title 36. Insurance

P. An insurer or a preferred provider organization shall not

unilaterally remove a provider from the network solely because the

provider informs an enrollee of the full range of physicians and

providers available to the enrollee including out-of-network

providers. Nothing in the Health Care Freedom of Choice Act

prohibits any insurer from allowing a contract to expire by its own

terms or negotiating a new contract with the provider at the end of

the contract term. A provider agreement shall not, as a condition

of the agreement, prohibit, penalize, terminate, or otherwise

restrict a preferred provider from referring to an out-of-network

provider; provided, the insured signs an acknowledgment of referral

that the insured may be responsible for:

1. Higher coinsurance and deductibles; and

2. Charges which exceed the allowable charges of a preferred

provider.

Added by Laws 1971, c. 183, § 5. Amended by Laws 1984, c. 26, § 1,

emerg. eff. March 22, 1984; Laws 1986, c. 251, § 43, eff. Nov. 1,

1986; Laws 1989, c. 37, § 2, eff. Nov. 1, 1989; Laws 1992, c. 370, §

2, eff. Sept. 1, 1992; Laws 1995, c. 356, § 1, eff. Nov. 1, 1995;

Laws 1996, c. 76, § 2, eff. Nov. 1, 1996; Laws 1999, c. 331, § 3,

eff. Nov. 1, 1999; Laws 2000, c. 127, § 1, eff. Nov. 1, 2000; Laws

2000, c. 350, § 1, eff. Nov. 1, 2000; Laws 2003, c. 288, § 2, eff.

Nov. 1, 2003; Laws 2009, c. 176, § 36, eff. Nov. 1, 2009; Laws 2021,

c. 217, § 1, eff. Nov. 1, 2021; Laws 2023, c. 158, § 2, eff. Nov. 1,

2023.