Oklahoma § 36-6558 - Information required to be submitted by private review

§ 36-6558. Information required to be submitted by private review

agents.

In conjunction with an application for a certificate, the

private review agent shall submit information that the Insurance

Commissioner requires, including, but not limited to:

1. A utilization review plan that includes:

a.

an adequate summary description of review standards,

protocol and procedures to be used in evaluating

proposed or delivered hospital and medical care,

b.

assurances that the standards and criteria to be

applied in review determinations are established with

input from health care providers representing major

areas of specialty and certified by the boards of the

various American medical specialties. The entity

Oklahoma Statutes - Title 36. Insurance

shall provide the Commissioner with a list of such

representatives and their major areas of specialty

upon request, and

c.

the provisions by which patients or health care

providers may seek reconsideration or appeal of

adverse decisions by the private review agent;

2. The type and qualifications of the personnel either employed

or under contract to perform the utilization review;

3. The procedures and policies to ensure that a representative

of the private review agent is reasonably accessible, if domiciled

in this state, to patients and health care providers five (5) days a

week during normal business hours, such procedures and policies to

include as a requirement a toll-free telephone number to be

available during said business hours; provided, in the alternative,

the out-of-state private review agent shall be available or make

staff available by toll-free telephone for at least forty (40) hours

per week during normal business hours and shall have a telephone

system which is capable of accepting or recording incoming telephone

calls during other than normal hours, and shall respond to such

calls within two (2) working days, if sufficient information is

provided to whomever accepts the call or on a recorded message;

4. The policies and procedures to ensure that all applicable

state and federal laws to protect the confidentiality of individual

medical records are followed;

5. The policies and procedures to verify the identity and

authority of personnel performing utilization review by telephone;

6. A copy of the materials designed to inform applicable

patients and health care providers of the requirements of the

utilization review plan;

7. A list of the third party payors for which the private

review agent is performing utilization review in this state. Said

list may be deemed confidential by the Commissioner for the purpose

of protecting competition between agents;

8. The procedures for receiving and handling complaints by

patients and health care providers concerning utilization review;

and

9. Procedures to ensure that after a request for medical

evaluation, treatment, or procedures has been rejected in whole or

in part and in the event a copy of the report on said rejection is

requested, a copy of the report of a private review agent concerning

the rejection shall be mailed by the insurer, postage prepaid, to

the ill or injured person, the treating health care provider or to

the person financially responsible for the patient's bill within

fifteen (15) days after receipt of the request for the report.

Added by Laws 1991, c. 294, § 8, eff. Nov. 1, 1991.

Oklahoma Statutes - Title 36. Insurance