Oklahoma § 36-6933 - Provision of basic health care services directly or by

§ 36-6933. Provision of basic health care services directly or by

contract or agreement - Standards and procedures for selection of

providers - Chiropractic and vision care services - Referrals.

A. A health maintenance organization shall provide basic health

care services directly or by contract or agreement with other

persons, corporations, institutions, associations, foundations or

other legal entities, public or private, in accordance with the laws

governing such professions and services.

B. Each health maintenance organization shall have a defined

set of standards and procedures for selecting providers, including

specialists, to serve enrollees. The standards and procedures shall

be drafted in such a manner as to be applicable to all categories of

providers and shall be utilized by the health maintenance

organization in a manner that is without bias for or discrimination

against a particular category or categories of providers.

C. With respect to chiropractic services, such covered services

shall be provided on a referral basis within the network at the

request of an enrollee who has a condition of an orthopedic or

neurological nature if:

1. A referral is necessitated in the judgment of the primary

care physician; and

2. Treatment for the condition falls within the licensed scope

of practice of a chiropractic physician.

D. 1. Any health maintenance organization that offers services

for vision care or medical diagnosis and treatment for the eye shall

allow optometrists to be providers of those services.

2. Once a fee schedule has been negotiated, ophthalmologists

and optometrists shall be paid equally for the same services so long

as the services provided by the optometrists are within the scope of

the practice of optometry.

Oklahoma Statutes - Title 36. Insurance

3. No health maintenance organization shall require a provider

of vision care or medical diagnosis and treatment for the eye to

have hospital privileges if hospital privileges are not usual and

customary for the services the provider provides.

4. With respect to optometric services, such covered services

shall be provided on a referral basis within the medical group or

network at the request of an enrollee who has a condition requiring

vision care or medical diagnosis and treatment of the eye if:

a.

a referral is necessitated in the judgment of the

primary care physician, and

b.

treatment for the condition falls within the licensed

scope of practice of an optometrist.

5. Nothing in this subsection shall be construed to:

a.

prohibit any health maintenance organization that

offers services for vision care or medical diagnosis

and treatment for the eye from determining the

adequacy of the size of its network,

b.

limit, expand or otherwise affect the scope of

practice of optometry, or

c.

alter, repeal, modify or affect the laws of this state

except where such laws are in conflict or are

inconsistent with the express provisions of this

section.

6. Existing contracts shall comply with the requirements of

this subsection upon issuance or renewal on or after the effective

date of this act.

E. 1. A health maintenance organization shall not:

a.

engage in the practice of medicine or any other

profession except as provided by law, or

b.

prohibit or restrict a primary care physician from

referring a patient to a specialist within the network

if such referral is deemed medically necessary in the

judgment of the primary care physician.

2. A health maintenance organization shall provide basic health

care services in a manner that is reasonably geographically

convenient to residents of the service area for which it seeks a

license.

Added by Laws 2003, c. 197, § 33, eff. Nov. 1, 2003.