Oklahoma § 36-6571 - Determination of average area or customary and reasonable

§ 36-6571. Determination of average area or customary and reasonable

charges - Disclosure to health care provider of information used.

A. As used in this section:

1. "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; and

2. "Insurer" means any insurance company, not-for-profit

hospital service and medical indemnity plan, health insurance

service organization, preferred provider organization or other

entity offering health insurance policies, contracts or benefits in

this state.

B. Any insurer which:

1. Makes a determination or contracts with a third party who

makes the determination of average area charges or customary and

reasonable charges for health care services, procedures or supplies;

and

2. Based on such determination, authorizes payment in an amount

which is less than the amount charged by the health care provider

for such services, procedures or supplies;

shall, upon the request of a health care provider, furnish the name,

mailing address and telephone number of the party making the

determination to the health care provider.

C. Upon the request of the health care provider, the party

shall furnish, for a reasonable charge, information used to

determine the average area charges or customary and reasonable

charges for the services, procedures or supplies provided by the

health care provider and authorized for payment pursuant to

paragraph 2 of subsection B of this section. The information shall

include the rationale and documentation of sources used in the

determination of the average area charges or customary and

reasonable charges for the services, procedures or supplies in

question, including names, mailing addresses and telephone numbers

of sources if available. Such information shall be furnished to the

health care provider no later than ten (10) working days after the

request for information by the health care provider.

D. 1. No insurer shall use the services of a party for the

determination of average area charges or customary and reasonable

charges which is not in compliance with the provisions of this

section.

2. Noncompliance shall be reported to the Insurance

Commissioner who, upon investigation of the complaint and

Oklahoma Statutes - Title 36. Insurance

determination that the party is in noncompliance and that no

resolution of the complaint will be made within a reasonable time,

shall compile and maintain a list of parties which are not in

compliance with the provisions of this section.

Added by Laws 1992, c. 297, § 1, eff. Sept. 1, 1992.