Oklahoma § 36-6475.5 - External review

§ 36-6475.5. External review

A. 1. A health carrier shall notify the covered person in

writing of the covered person's right to request an external review

to be conducted pursuant to Section 6475.8, 6475.9, or 6475.10 of

this title and include the appropriate statements and information

set forth in subsection B of this section at the same time the

health carrier sends written notice of:

a.

an adverse determination upon completion of the health

carrier's utilization review process set forth in

Sections 6551 through 6565 of this title, and

b.

a final adverse determination.

2. As part of the written notice required under paragraph 1 of

this subsection, a health carrier shall include the following, or

substantially equivalent, language: "We have denied your request

for the provision of or payment for a health care service or course

of treatment. You may have the right to have our decision reviewed

Oklahoma Statutes - Title 36. Insurance

by health care professionals who have no association with us if our

decision involved making a judgment as to the medical necessity,

appropriateness, health care setting, level of care or effectiveness

of the health care service or treatment you requested by submitting

a request for external review to the Oklahoma Insurance Department."

3. The Insurance Commissioner may promulgate any necessary rule

providing for the form and content of the notice required under this

section.

B. 1. The health carrier shall include in the notice required

under subsection A of this section:

a.

for a notice related to an adverse determination, a

statement informing the covered person that:

(1) if the covered person has a medical condition

where the time frame for completion of an

expedited review of a grievance involving an

adverse determination would seriously jeopardize

the life or health of the covered person or would

jeopardize the covered person's ability to regain

maximum function, the covered person or the

covered person's authorized representative may

file a request for an expedited external review

to be conducted pursuant to Section 6475.10 of

this title, or Section 6475.11 of this title if

the adverse determination involves a denial of

coverage based on a determination that the

recommended or requested health care service or

treatment is experimental or investigational and

the covered person's treating physician certifies

in writing that the recommended or requested

health care service or treatment that is the

subject of the adverse determination would be

significantly less effective if not promptly

initiated, at the same time the covered person or

the covered person's authorized representative

files a request for an expedited review of a

grievance involving an adverse determination, but

that the independent review organization assigned

to conduct the expedited external review will

determine whether the covered person shall be

required to complete the expedited review of the

grievance prior to conducting the expedited

external review, and

(2) the covered person or the covered person's

authorized representative may file a grievance

under the health carrier's internal grievance

process, but if the health carrier has not issued

a written decision to the covered person or the

Oklahoma Statutes - Title 36. Insurance

b.

covered person's authorized representative within

thirty (30) days following the date the covered

person or the covered person's authorized

representative files the grievance with the

health carrier and the covered person or the

covered person's authorized representative has

not requested or agreed to a delay, the covered

person or the covered person's authorized

representative may file a request for external

review pursuant to Section 6475.6 of this title

and shall be considered to have exhausted the

health carrier's internal grievance process for

purposes of Section 6475.7 of this title, and

for a notice related to a final adverse determination,

a statement informing the covered person that:

(1) if the covered person has a medical condition

where the time frame for completion of a standard

external review pursuant to Section 6475.8 of

this title would seriously jeopardize the life or

health of the covered person or would jeopardize

the covered person's ability to regain maximum

function, the covered person or the covered

person's authorized representative may file a

request for an expedited external review pursuant

to Section 6475.9 of this title, or

(2) if the final adverse determination concerns:

(a) an admission, availability of care,

continued stay or health care service for

which the covered person received emergency

services, but has not been discharged from a

facility, the covered person or the covered

person's authorized representative may

request an expedited external review

pursuant to Section 6475.9 of this title, or

(b) a denial of coverage based on a

determination that the recommended or

requested health care service or treatment

is experimental or investigational, the

covered person or the covered person's

authorized representative may file a request

for a standard external review to be

conducted pursuant to Section 6475.10 of

this title or if the covered person's

treating physician certifies in writing that

the recommended or requested health care

service or treatment that is the subject of

the request would be significantly less

Oklahoma Statutes - Title 36. Insurance

effective if not promptly initiated, the

covered person or the covered person's

authorized representative may request an

expedited external review to be conducted

under Section 6475.10 of this title.

2. In addition to the information to be provided pursuant to

paragraph 1 of this subsection, the health carrier shall include a

copy of the description of both the standard and expedited external

review procedures the health carrier is required to provide pursuant

to Section 6475.17 of this title, highlighting the provisions in the

external review procedures that give the covered person or the

covered person's authorized representative the opportunity to submit

additional information and including any forms used to process an

external review.

3. As part of any forms provided under paragraph 2 of this

subsection, the health carrier shall include an authorization form,

or other document approved by the Commissioner that complies with

the requirements of 45 CFR, Section 164.508, by which the covered

person, for purposes of conducting an external review under this

act, authorizes the health carrier and the covered person's treating

health care provider to disclose protected health information

including medical records, concerning the covered person that are

pertinent to the external review.

Added by Laws 2011, c. 278, § 39. Amended by Laws 2011, c. 360, §

29; Laws 2022, c. 154, § 12, eff. Nov. 1, 2022.