Oklahoma § 36-6570.9 - Treatment of chronic conditions — Validity period for

§ 36-6570.9. Treatment of chronic conditions — Validity period for

prior authorization of inpatient and non-inpatient care.

A. If a prior authorization is required for a health care

service, other than for inpatient care, for the treatment of a

chronic condition of an enrollee, then the prior authorization shall

remain valid for at least six (6) months from the date the health

care provider receives the prior authorization approval, unless

clinical criteria changes and notice of the change in clinical

criteria is provided as stipulated in this act.

B. If a prior authorization is required for inpatient acute

care for the treatment of a chronic condition of an enrollee, then

the prior authorization shall remain valid for at least fourteen

(14) calendar days from the date the health care provider receives

the prior authorization approval.

1. If an enrollee requires inpatient care beyond the length of

stay that was previously approved by the utilization review entity,

then the utilization review entity shall evaluate any prior

authorization requests for the continuation of inpatient care

according to the provisions of this act. A utilization review

entity shall not use any stricter criteria to determine medical

necessity and appropriateness of the continuation of inpatient care

as the utilization review entity used to evaluate the initial

request for authorization of inpatient care. A utilization review

entity shall review any relevant and pertinent literature or data

provided by the health care provider to determine the medical

necessity and appropriateness of the requested length of stay and/or

continuation of inpatient care. A prior authorization for the

Oklahoma Statutes - Title 36. Insurance

continuation of inpatient care shall remain valid for a maximum of

fourteen (14) calendar days from the date the health care provider

receives the prior authorization approval.

2. If a utilization review entity fails to respond to a health

care provider's timely prior authorization request for the

continuation of inpatient acute care before the termination of the

previously approved length of stay, then the health benefit plan

shall continue to compensate the health care provider at the

contracted rate for inpatient care provided until the utilization

review entity issues its determination on the prior authorization

request.

For the purposes of this section, a timely request for

continuation of inpatient care means a request that is submitted at

least twenty-four (24) hours prior to the termination of the

previously approved prior authorization and includes all necessary

information for the utilization review entity to make a

determination.

3. If a utilization review entity issues an adverse

determination to a health care provider's prior authorization

request for continuation of inpatient acute care and the health care

provider appeals the adverse determination according to the

provisions of this act, then the health benefit plan shall continue

to compensate the health care provider at the contracted rate for

inpatient care provided until the appeal has been finalized.

C. This section does not require a health benefit plan to cover

care, treatment, or services for a health condition that the terms

of coverage otherwise completely exclude from the policy's covered

benefits without regard for whether the care, treatment, or services

are medically necessary.

Added by Laws 2024, c. 303, § 10, eff. Jan. 1, 2025. Amended by

Laws 2025, c. 181, § 1, eff. Nov. 1, 2025.