Oklahoma § 36-6552 - Definitions

§ 36-6552. Definitions

As used in the Hospital and Medical Services Utilization Review

Act:

1. "Utilization review" means a system for prospectively,

concurrently and retrospectively reviewing the appropriate and

efficient allocation of hospital resources and medical services

given or proposed to be given to a patient or group of patients. It

does not include an insurer's normal claim review process to

determine compliance with the specific terms and conditions of the

insurance policy;

2. "Private review agent" means a person or entity who performs

utilization review on behalf of:

a.

an employer in this state, or

b.

a third party that provides or administers hospital

and medical benefits to citizens of this state,

including, but not limited to:

(1) a health maintenance organization issued a

license pursuant to Section 2501 et seq. of Title

63 of the Oklahoma Statutes, unless the health

maintenance organization is federally regulated

and licensed and has on file with the Insurance

Commissioner a plan of utilization review carried

out by health care professionals and providing

for complaint and appellate procedures for

claims, or

(2) a health insurer, not-for-profit hospital service

or medical plan, health insurance service

Oklahoma Statutes - Title 36. Insurance

organization, or preferred provider organization

or other entity offering health insurance

policies, contracts or benefits in this state;

3. "Utilization review plan" means a description of utilization

review procedures;

4. "Commissioner" means the Insurance Commissioner;

5. "Certificate" means a certificate of registration granted by

the Insurance Commissioner to a private review agent; and

6. "Health care provider" means any person, firm, corporation

or other legal entity that is licensed, certified, or otherwise

authorized by the laws of this state to provide health care

services, procedures or supplies in the ordinary course of business

or practice of a profession.

Added by Laws 1991, c. 294, § 2, eff. Nov. 1, 1991. Amended by

Laws 2021, c. 478, § 34, emerg. eff. May 12, 2021.