Oklahoma § 36-6475.7 - External review procedure

§ 36-6475.7. External review procedure

A. 1. Except as provided in subsection B of this section, a

request for an external review pursuant to Section 6475.8, 6475.9,

or 6475.10 of this title shall not be made until the covered person

has exhausted the health carrier's internal grievance process.

2. A covered person shall be considered to have exhausted the

health carrier's internal grievance process for purposes of this

Oklahoma Statutes - Title 36. Insurance

section, if the covered person or the covered person's authorized

representative:

a.

has filed a grievance involving an adverse

determination, and

b.

except to the extent the covered person or the covered

person's authorized representative requested or agreed

to a delay, has not received a written decision on the

grievance from the health carrier within thirty (30)

days following the date the covered person or the

covered person's authorized representative filed the

grievance with the health carrier.

3. Notwithstanding paragraph 2 of this subsection, a covered

person or the covered person's authorized representative may not

make a request for an external review of an adverse determination

involving a retrospective review determination made pursuant to

Sections 6551 through 6565 of this title until the covered person

has exhausted the health carrier's internal grievance process.

B. 1. a. At the same time a covered person or the covered

person's authorized representative files a request for

an expedited review of a grievance involving an

adverse determination, the covered person or the

covered person's authorized representative may file a

request for an expedited external review of the

adverse determination:

(1) under Section 6475.9 of this title if the covered

person has a medical condition where the time

frame for completion of an expedited review of

the 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, or

(2) under Section 6475.10 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.

b.

Upon receipt of a request for an expedited external

review under subparagraph a of this paragraph, the

independent review organization conducting the

external review in accordance with the provisions of

Oklahoma Statutes - Title 36. Insurance

Section 6475.9 or 6475.10 of this title shall

determine whether the covered person shall be required

to complete the expedited review process before it

conducts the expedited external review.

c.

Upon a determination made pursuant to subparagraph b

of this paragraph that the covered person must first

complete the expedited grievance review process, the

independent review organization immediately shall

notify the covered person and, if applicable, the

covered person's authorized representative of this

determination and that it will not proceed with the

expedited external review set forth in Section 6475.9

of this title until completion of the expedited

grievance review process and the covered person's

grievance at the completion of the expedited grievance

review process remains unresolved.

2. A request for an external review of an adverse determination

may be made before the covered person has exhausted the health

carrier's internal grievance procedures whenever the health carrier

agrees to waive the exhaustion requirement.

C. If the requirement to exhaust the health carrier's internal

grievance procedures is waived under paragraph 2 of subsection B of

this section, the covered person or the covered person's authorized

representative may file a request in writing for a standard external

review as set forth in Section 6475.8 or 6475.10 of this title.

Added by Laws 2011, c. 278, § 41. Amended by Laws 2011, c. 360, §

31; Laws 2022, c. 154, § 14, eff. Nov. 1, 2022.