56 OK Stat § 56-4002.6 (2021)
2021 Oklahoma Statutes|Title 56. Poor Persons|§56-4002.6. Determination and review requirements.

|A. A managed care organization shall make a determination on a request for an authorization of the transfer of a hospital inpatient to a post-acute care or long-term acute care facility within twenty-four (24) hours of receipt of the request. |B. Review and issue determinations made by a managed care organization or, as appropriate, by a dental benefit manager for prior authorization for care ordered by primary care or specialist providers shall be timely and shall occur in accordance with the following:1. Within seventy-two (72) hours of receipt of the request for any patient who is not hospitalized at the time of the request; provided, that if the request does not include sufficient or adequate documentation, the review and issue determination shall occur within a time frame and in accordance with a process established by the Authority. The process established by the Authority pursuant to this paragraph shall include a time frame of at least forty-eight (48) hours within which a provider may submit the necessary documentation;2. Within one (1) business day of receipt of the request for services for a hospitalized patient including, but not limited to, acute care inpatient services or equipment necessary to discharge the patient from an inpatient facility;3. Notwithstanding the provisions of paragraphs 1 or 2 of this subsection, as expeditiously as necessary and, in any event, within twenty-four (24) hours of receipt of the request for service if adhering to the provisions of paragraphs 1 or 2 of this subsection could jeopardize the enrollee's life, health or ability to attain, maintain or regain maximum function. In the event of a medically emergent matter, the managed care organization or dental benefit manager shall not impose limitations on providers in coordination of post-emergent stabilization health care including pre-certification or prior authorization;4. Notwithstanding any other provision of this subsection, within twenty-four (24) hours of receipt of the request for inpatient behavioral health services; and5. Within twenty-four (24) hours of receipt of the request for covered prescription drugs that are required to be prior authorized by the Authority. The managed care organization shall not require prior authorization on any covered prescription drug for which the Authority does not require prior authorization.C. Upon issuance of an adverse determination on a prior authorization request under subsection B of this section, the managed care organization or dental benefit manager shall provide the requesting provider, within seventy-two (72) hours of receipt of such issuance, with reasonable opportunity to participate in a peer-to-peer review process with a provider who practices in the same specialty, but not necessarily the same sub-specialty, and who has experience treating the same population as the patient on whose behalf the request is submitted; provided, however, if the requesting provider determines the services to be clinically urgent, the managed care organization or dental benefit manager shall provide such opportunity within twenty-four (24) hours of receipt of such issuance. Services not covered under the state Medicaid program for the particular patient shall not be subject to peer-to-peer review.D. The Authority shall ensure that a provider offers to provide to an enrollee in a timely manner services authorized by a managed care organization or dental benefit manager.Added by Laws 2021, c. 542, § 6, eff. Sept. 1, 2021.