Oklahoma § 56-4002.7 - Requirements for processing and adjudicating claims

§ 56-4002.7. Requirements for processing and adjudicating claims

A. The Oklahoma Health Care Authority shall establish

requirements for fair processing and adjudication of claims that

ensure prompt reimbursement of providers by contracted entities. A

contracted entity shall comply with all such requirements.

B. A contracted entity shall process a clean claim in the time

frame provided by Section 1219 of Title 36 of the Oklahoma Statutes

and no less than ninety percent (90%) of all clean claims shall be

paid within fourteen (14) days of submission to the contracted

entity. A clean claim that is not processed within the time frame

provided by Section 1219 of Title 36 of the Oklahoma Statutes shall

bear simple interest at the monthly rate of one and one-half percent

Oklahoma Statutes - Title 56. Poor Persons

(1.5%) payable to the provider. A claim filed by a provider within

six (6) months of the date the item or service was furnished to a

member shall be considered timely. If a claim meets the definition

of a clean claim, the contracted entity shall not request medical

records of the member prior to paying the claim. Once a claim has

been paid, the contracted entity may request medical records if

additional documentation is needed to review the claim for medical

necessity.

C. In the case of a denial of a claim including, but not

limited to, a denial on the basis of the level of emergency care

indicated on the claim, or in the case of a downcoded claim, the

contracted entity shall establish a process by which the provider

may identify and provide such additional information as may be

necessary to substantiate the claim. Any such claim denial or

downcode shall include the following:

1. A detailed explanation of the basis for the denial; and

2. A detailed description of the additional information

necessary to substantiate the claim.

D. Postpayment audits by a contracted entity shall be subject

to the following requirements:

1. Subject to paragraph 2 of this subsection, insofar as a

contracted entity conducts postpayment audits, the contracted entity

shall employ the postpayment audit process determined by the

Authority;

2. The Authority shall establish a limit on the percentage of

claims with respect to which postpayment audits may be conducted by

a contracted entity for health care items and services furnished by

a provider in a plan year; and

3. The Authority shall provide for the imposition of financial

penalties under such contract in the case of any contracted entity

with respect to which the Authority determines has a claims denial

error rate of greater than five percent (5%). The Authority shall

establish the amount of financial penalties and the time frame under

which such penalties shall be imposed on contracted entities under

this paragraph, in no case less than annually.

E. A contracted entity may only apply readmission penalties

pursuant to rules promulgated by the Oklahoma Health Care Authority

Board. The Board shall promulgate rules establishing a program to

reduce potentially preventable readmissions. The program shall use

a nationally recognized tool, establish a base measurement year and

a performance year, and provide for risk-adjustment based on the

population of the state Medicaid program covered by the contracted

entities.

Added by Laws 2021, c. 542, § 7, eff. Sept. 1, 2021. Amended by

Laws 2022, c. 395, § 11, eff. July 1, 2022; Laws 2024, c. 448, § 6,

emerg. eff. June 14, 2024.

Oklahoma Statutes - Title 56. Poor Persons