Oklahoma § 36-6592 - Definitions

§ 36-6592. Definitions

For purposes of this act:

1. "Enrollee" means an individual who is enrolled in a health

care plan, including covered dependents;

2. "Health care plan" means any arrangement whereby any person

undertakes to provide, arrange for, pay for, or reimburse any part

of the costs of any health care services for an enrollee;

Oklahoma Statutes - Title 36. Insurance

3. "Health care provider" means a physician, hospital,

pharmaceutical company, pharmacy, pharmacist, laboratory, or other

state-licensed or state-recognized provider of health care services;

4. "Health insurance carrier" means an insurance company that

issues policies of accident and health insurance and is or should be

licensed to sell insurance in this state;

5. "Health maintenance organization" means an organization

which is or should be licensed by the State Department of Health

pursuant to Section 2501 et seq. of Title 63 of the Oklahoma

Statutes;

6. "Managed care entity" means any entity which is a health

care plan, health insurance carrier or health maintenance

organization as defined in this section, but does not include an

employer that sponsors or participates in a health care plan or

purchases coverage or assumes risk on behalf of or for the benefit

of its employees or the employees of one or more subsidiaries or

affiliates of the employer; and

7. "Medically necessary” means services or supplies provided by

a health care provider that are:

a.

appropriate for the symptoms and diagnosis or

treatment of the enrollee’s condition, illness,

disease, or injury,

b.

in accordance with standards of good medical practice,

c.

not primarily for the convenience of the enrollee or

the enrollee’s health care provider, and

d.

the most appropriate supply or level of service that

can safely be provided to the enrollee.

Added by Laws 2000, c. 163, § 2, eff. July 1, 2000.