reglab/statecodes huggingface dataset:
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5010. Analysis of state health care programs - Exploration of cost containment and delivery alternatives.

A. The Oklahoma Health Care Authority shall analyze the state-purchased and state-subsidized health care programs and explore options for cost containment and delivery alternatives for those programs that are consistent with the purposes of those programs, including, but not limited to:
1. Creation of economic incentives for the persons for whom the state purchases or subsidizes health care to appropriately utilize and purchase health care services, including the development of flexible benefit plans to offset increases in individual financial responsibility;
2. Utilization of provider arrangements that encourage cost containment and ensure access to quality care, including, but not limited to, prepaid delivery systems, utilization review, and prospective payment methods;
3. Coordination of state agency efforts to purchase drugs effectively;
4. Development of recommendations and methods for purchasing medical equipment and supporting services on a volume discount basis; and
5. Development of data systems to obtain utilization data from state-purchased and state-subsidized health care programs in order to identify cost centers, utilization patterns, provider and hospital practice patterns, and procedure costs.
B. 1. The Authority shall prepare for the Governor, the Legislature and the Joint Legislative Oversight Committee for the Oklahoma Health Care Authority an annual report on the savings realized and all costs incurred in the implementation of any drug cost containment programs including, but not limited to:
a.
development and implementation of a drug prior authorization list, and
b.
other uses of prior authorizations.
2. Costs shall include direct costs such as staffing, contracts and other resources used.
Added by Laws 1993, c. 332, § 8. Amended by Laws 2004, c. 218, § 1, eff. Nov. 1, 2004.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5011.1. State-purchased health care benefits – Optometrists to be permitted to provide vision care or medical diagnosis and treatment of the eye.

A. All state-purchased and state-subsidized health care benefit plans, including but not limited to Medicaid, which offer services for vision care or medical diagnosis and treatment for the eye shall allow optometrists to be providers of those services. Such state-purchased and state-subsidized health care benefit plans shall also require equal payment for the same services provided by an optometrist if the services are within the scope of practice of optometry.
B. With respect to optometric services, any state-purchased and state-subsidized health care benefit plan, including but not limited to Medicaid, which uses a gatekeeper or equivalent for referrals for services for vision care or for medical diagnosis and treatment of the eye, shall require such covered services 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:
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 an optometrist.
C. All state-purchased and state-subsidized health care benefit plans 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 that they are applicable to all categories of providers and shall be utilized by the health plan in a manner that is without bias for or discrimination against a particular category or categories of providers.
D. No health care benefit plan specified by this section shall require a provider to have hospital privileges if hospital privileges are not usual and customary for the services the provider provides.
E. Nothing in this section shall be construed to:
1. Prohibit any state-purchased and state-subsidized health care benefit plan which offers services for vision care or medical diagnosis and treatment for the eye from determining the adequacy of the size of its network;
2. Prohibit an optometrist from agreeing to a fee schedule;
3. Limit, expand, or otherwise affect the scope of practice of optometry; or
4. 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.
F. Existing state-purchased and state-subsidized health care benefit plans shall comply with the requirements of this section upon issuance or renewal on or after the effective date of this act.
Added by Laws 2000, c. 54, § 3, eff. Nov. 1, 2000.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5012. Submission of plans, proposals and recommendations to Legislature - Contents.

On or before January 1, 1996, the Authority shall submit plans, recommendations and proposals to the Governor and the Legislature regarding state-purchased and state subsidized health care. Said plans, proposals and recommendations shall include, but not be limited to:
1. A plan for local and regional health planning for health care delivery;
2. A proposal for the containment of health care costs;
3. In collaboration with the Oklahoma State Regents, a proposal for enhancing the number of primary care physicians and physician extenders graduating from schools in Oklahoma and remaining to practice within the state. The plan shall include recommendations for improving access to basic health care through more effective utilization of allied health care professionals and appropriate geographic distribution of physicians and other health care professionals;
4. A plan for facilitating the use of practice parameters based upon outcomes research;
5. A proposal for the utilization of Resource Based-Relative Value System for use as a rate schedule by third-party payors and health care providers; and
6. A plan to reduce liability exposure and expense for all health care providers.
Added by Laws 1993, c. 332, § 10.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5013. Authority as resource for information on state health care access, cost containment and related health issues.

A. The Authority shall serve as a resource for information on state-purchased and state-subsidized health care access, cost containment and related health issues, and shall:
1. Provide data and information required by the Governor, the Legislature, or its committees, and to state agencies, institutions of higher education and cities, towns, counties and school districts and to private citizens and groups, within the limitations of the resources available to the Authority;
2. Participate with any state agency or institution of higher education in developing specific goals, programs, and performance monitoring systems to assist in the development of health care delivery in this state;
3. Conduct or contract for studies which are related to health care delivery, involving product or process innovation; and
4. Prepare, publish and distribute such studies, reports, bulletins and other materials as it considers appropriate regarding health care studies and other relevant health care topics. Provided that a copy of any material which evaluates health plans or health care providers shall be provided to the Governor, the Speaker of the House of Representatives and the President Pro Tempore of the Senate at least sixty (60) days prior to public dissemination.
Added by Laws 1993, c. 332, § 11. Amended by Laws 1996, c. 355, § 1, eff. July 1, 1996.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5013.1. Persons providing Medicaid home- and community-based personal care services pursuant to contract with Authority.

A. An individual who only provides Medicaid home- and community-based personal care services, pursuant to a contract with the Oklahoma Health Care Authority, shall be exempt from the provisions of the Home Care Act, Section 1-1960 et seq. of Title 63 of the Oklahoma Statutes.
B. The Authority, with the assistance of the Aging Services Division of the Department of Human Services, shall develop qualifying criteria that comply with federal standards for personal care services under the Medicaid program for persons providing Medicaid home- and community-based personal care services pursuant to a contract with the Oklahoma Health Care Authority. Such criteria shall also include requirements for a criminal history investigation to be conducted on such persons pursuant to Section 1-1950.1 of Title 63 of the Oklahoma Statutes.
Added by Laws 1997, c. 219, § 3, emerg. eff. May 19, 1997.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5015. Review of state-purchased and state-subsidized health care programs and regulatory agencies - Report to Legislature.

The Oklahoma Health Care Authority shall review state-purchased and state-subsidized health care programs and health care regulatory agencies, including, but not limited to, medical services within the Department of Mental Health and Substance Abuse Services, the Department of Veterans Affairs, the Department of Human Services, the State Department of Health, the Oklahoma Medical Center, the State Education and Employees Group Insurance Board, and any other state-purchased and state-subsidized health care programs as deemed appropriate by the administrator, and submit to the Legislature, no later than December 1, 1995, an initial report including, but not limited to:
1. A description of the respective roles of these programs and agencies regarding health care cost containment;
2. A plan to increase the combined efficiency of these programs and agencies to control costs and maintain or improve access to quality care;
3. Methods to ensure coordination between these programs and agencies and the Authority;
4. An analysis of the real and potential impacts of cost shifting; and
5. Recommendations regarding structural changes in the state's current health care delivery system.
Added by Laws 1993, c. 332, § 13. Amended by Laws 1997, c. 109, § 3, eff. Nov. 1, 1997.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5015.1. Legal division or unit.

A. The Oklahoma Health Care Authority Board shall establish a legal division or unit in the Oklahoma Health Care Authority. The Administrator of the Oklahoma Health Care Authority may employ attorneys as needed, which may be on full-time and part-time basis. Provided the Oklahoma Health Care Authority shall not exceed the authorized full-time equivalent limit for attorneys as specified by the Legislature in the appropriations bill for the Authority. Except as otherwise provided by this section, such attorneys, in addition to advising the Board, Administrator and Authority personnel on legal matters, may appear for and represent the Board, Administrator and Authority in legal actions and proceedings.
B. The Legislature shall establish full-time-equivalent limits for attorneys employed by the Oklahoma Health Care Authority.
C. It shall continue to be the duty of the Attorney General to give official opinions to the Board, Administrator and Authority, and to prosecute and defend actions therefor, if requested to do so. The Attorney General may levy and collect costs, expenses of litigation and a reasonable attorney fee for such legal services from the Authority. The Attorney General is authorized to levy and collect costs, expenses and fees which exceed the costs associated with the salary and benefits of one attorney FTE position per fiscal year.
D. The Board, Administrator or Authority shall not contract for representation by private legal counsel unless approved by the Attorney General. Such contract for private legal counsel shall be in the best interests of the state.
E. 1. The Attorney General shall be notified by the Board or its counsel of all lawsuits against the Authority, its officers or employees that seek injunctive relief which would impose obligations requiring the expenditure of funds in excess of unencumbered monies in the agency's appropriations or beyond the current fiscal year.
2. The Attorney General shall review any such cases and may represent the interests of the state, if the Attorney General considers it to be in the best interest of the state to do so, in which case the Attorney General shall be paid as provided in subsection C of this section. Representation of multiple defendants in such actions may, at the discretion of the Attorney General, be divided with counsel for the Board, Administrator and Authority as necessary to avoid conflicts of interest.
Added by Laws 1995, c. 95, § 1, emerg. eff. April 13, 1995.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5016. Oklahoma Health Care Authority Revolving Fund.

There is hereby created in the State Treasury a revolving fund for the Oklahoma Health Care Authority to be designated the "Oklahoma Health Care Authority Revolving Fund". The fund shall be a continuing fund, not subject to fiscal year limitations, and shall consist of all monies received by the Authority, from any source. All monies accruing to the credit of said fund are hereby appropriated and may be budgeted and expended by the Authority for any purpose authorized by law. Expenditures from said fund shall be made upon warrants issued by the State Treasurer against claims filed as prescribed by law with the Director of the Office of Management and Enterprise Services for approval and payment.
Added by Laws 1993, c. 332, § 14. Amended by Laws 2012, c. 304, § 523.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5017. Oklahoma Health Care Authority Federal Disallowance Fund.

There is hereby created in the State Treasury a fund for the Oklahoma Health Care Authority to be designated the "Oklahoma Health Care Authority Federal Disallowance Fund". The fund shall be a continuing fund, not subject to fiscal year limitations. It shall consist of monies received by the Oklahoma Health Care Authority which, in the opinion of the Oklahoma Health Care Authority Board, may be subject to federal disallowances and interest which may accrue on said receipts. All monies accruing to the credit of said fund are hereby appropriated and may be budgeted and expended by the Oklahoma Health Care Authority at the discretion of the Oklahoma Health Care Authority Board for eventual settlement of the appropriate pending disallowances. Expenditures from said fund shall be made upon warrants issued by the State Treasurer against claims filed as prescribed by law with the Director of the Office of Management and Enterprise Services for approval and payment.
The Administrator of the Oklahoma Health Care Authority may request the Director of the Office of Management and Enterprise Services to transfer monies between the Oklahoma Health Care Authority Federal Disallowance Fund and any other fund of the authority, as needed for the expenditure of funds.
Added by Laws 1995, c. 96, § 1, eff. July 1, 1995. Amended by Laws 2012, c. 304, § 524.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5018. Confidentiality of Medicaid applications and records - Disclosure to authorized representative.

All applications and records concerning any applicant or recipient under the Medicaid Program shall be confidential and shall be open to inspection only to persons duly authorized by the Oklahoma Health Care Authority, this state, or the United States, and for purposes directly related to plan administration. Provided, however, the Oklahoma Health Care Authority shall maintain a process to allow an authorized representative of a client of the State Medicaid Program to have access to confidential information when necessary for eligibility determination and the appeals process. For purposes of this section, "authorized representative" shall mean any person designated by a client of the State Medicaid Program to review confidential information about the client pertinent to eligibility determination and the appeals process. For purposes of this section, "purposes directly related to plan administration" means establishing eligibility, determining the amount of medical assistance, providing services to recipients, conducting or assisting with an investigation or prosecution, or civil or criminal proceedings in relation to the administration of the State Medicaid Program.
Applications and records considered confidential are those which disclose:
1. The name and address of the recipient;
2. The medical services provided;
3. The recipient's social and economic circumstances;
4. The agency's evaluation of personal information;
5. The medical data which includes but is not limited to diagnosis and past history of disease and disability; and
6. Any information received for the purpose of verifying income eligibility and determining the amount of medical assistance payments.
Added by Laws 1995, c. 170, § 3, emerg. eff. May 8, 1995.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5018.1. Concurrent applications by active duty military members.

If a person who is on active duty with the United States Armed Forces makes an application to the Oklahoma Health Care Authority to receive any type of benefits, either for himself or herself or for an immediate family member, and the person has previously made the same or a substantially similar application in another state which was pending at the time the person became a resident of this state, the Authority shall consider the application as if it had been made in this state at the time it was originally made in the other state.
Added by Laws 2015, c. 66, § 2, eff. Nov 1, 2015.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5020. Oklahoma Health Care Authority Medicaid Program Fund.

There is hereby created in the State Treasury a fund for the Oklahoma Health Care Authority to be designated the "Oklahoma Health Care Authority Medicaid Program Fund". The fund shall be a continuing fund, not subject to fiscal year limitations. All monies accruing to the credit of said fund are hereby appropriated and may be budgeted and expended by the Oklahoma Health Care Authority at the discretion of the Oklahoma Health Care Authority Board. Expenditures from said fund shall be made upon warrants issued by the State Treasurer against claims filed as prescribed by law with the Director of the Office of Management and Enterprise Services for approval and payment.
The Administrator of the Oklahoma Health Care Authority may request the Director of the Office of Management and Enterprise Services to transfer monies between the Oklahoma Health Care Authority Medicaid Program Fund and any other fund of the Authority, as needed for the expenditure of funds.
Added by Laws 1995, c. 306, § 6, eff. July 1, 1995. Amended by Laws 2012, c. 304, § 525.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5020A. Rate Preservation Fund.

There is hereby created in the State Treasury a fund for the Oklahoma Health Care Authority to be designated the "Rate Preservation Fund". The fund shall be a continuing fund, not subject to fiscal year limitations, and shall consist of monies designated to the fund by law. All monies accruing to the credit of the fund are hereby appropriated and may be budgeted and expended by the Authority for the sole purpose of maintaining reimbursement rates to providers. Expenditures from the fund shall be made upon warrants issued by the State Treasurer against claims filed as prescribed by law with the Director of the Office of Management and Enterprise Services for approval and payment. The Administrator of the Authority may request the Director of the Office of Management and Enterprise Services to transfer monies between the Rate Preservation Fund and any other fund of the Authority as needed for the expenditure of funds.
Added by Laws 2019, c. 447, § 1, emerg. eff. May 24, 2019. Amended by Laws 2020, c. 13, § 1.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5022.2. Nursing facilities liability insurance costs – Medicaid reimbursement.

The Oklahoma Health Care Authority shall promulgate rules which shall provide that the liability insurance costs of nursing facilities shall be allowable costs for purposes of Medicaid reimbursement.
Added by Laws 2000, c. 340, § 6, eff. July 1, 2000.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5023. Adjustment of per diem rate – Medicaid savings.

Effective January 1, 2000, and every January thereafter, the Oklahoma Health Care Authority will adjust the nursing facility per diem rate in an amount equal to the total amount of the savings to the Medicaid program as a result of the automatic cost-of-living adjustment on Social Security benefits received by nursing home recipients, as published in the Federal Register.
Added by Laws 1999, c. 348, § 3, eff. July 1, 1999.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5024. Incorporated physician providers – Income deferral programs.

A. 1. Effective July 1, 2001, the Oklahoma Health Care Authority is authorized to offer to eligible contracted incorporated physician providers, elective income deferral programs which can result in federal income tax advantages and other advantages to such providers and their employees. These deferral programs shall take into account present and future provisions of the United States Internal Revenue Code which now or in the future might have the beneficial effect of magnifying the after-tax value payments made by the state to incorporated physician providers.
2. The Oklahoma Health Care Authority may adopt a plan that provides for the investment of deferral amounts in life insurance or annuity contracts which offer a choice of underlying investment options. Contract-issuing companies shall be limited to companies that are licensed to do business in this state.
3. As a condition of participation in these income deferral programs, all participating incorporated physician providers shall be subject to provisions for forfeiture of benefits for failure to maintain in force a Medicaid provider agreement and to furnish services to Medicaid recipients for a specified duration.
B. The Oklahoma Health Care Authority may consult with the State Treasurer and the Attorney General of the state for advice in establishing the program.
C. The Oklahoma Health Care Authority Board shall have the authority to promulgate rules regarding the operation of the program.
Added by Laws 2001, c. 147, § 2, emerg. eff. April 30, 2001. Amended by Laws 2001, c. 317, § 6, emerg. eff. June 1, 2001; Laws 2002, c. 122, § 1.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5025. Reimbursement methodology - Established.

The Oklahoma Health Care Authority may establish, with available funds, a reimbursement methodology that will enhance the reimbursement for services provided to Medicaid beneficiaries in emergency hospitals in rural areas of the state.
Added by Laws 2001, c. 317, § 2, eff. Nov. 1, 2001.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5026. Medicaid prescription drug program – Definition of phenylketonuria.

A. The Oklahoma Health Care Authority Board shall, in administering the Medicaid prescription drug program, utilize the following definition for "phenylketonuria" to mean: An inborn error of metabolism attributable to a deficiency of or a defect in phenylalanine hydroxylase, the enzyme that catalyzes the conversion of phenylalanine to tyrosine. The deficiency permits the accumulation of phenylalanine and its metabolic products in the body fluids. The deficiency can result in intellectual disabilities (phenylpyruvic oligophrenia), neurologic manifestations (including hyperkinesia, epilepsy, and microcephaly), light pigmentation, and eczema. The disorder is transmitted as an autosomal recessive trait and can be treated by administration of a diet low in phenylalanine.
B. The Oklahoma Health Care Authority Board shall promulgate any rules necessary to effectuate the provisions of this section.
Added by Laws 2005, c. 452, § 2, eff. Nov. 1, 2005. Amended by Laws 2019, c. 475, § 58, eff. Nov. 1, 2019.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5026.1. Annual review of all medications and forms of treatment for sickle cell disease.

A. The Oklahoma Health Care Authority shall conduct an annual review of all medications and forms of treatment for sickle cell disease and services for enrollees with a diagnosis of sickle cell disease. The purpose of the annual review is to determine if the available covered medications, treatments, and services are adequate to meet the needs of enrollees with a diagnosis of sickle cell disease, and whether the Authority should seek to add or recommend additional medications, treatments, or services.
B. The review shall include, but not be limited to:
1. The extent to which healthcare transitional programs covered under the state Medicaid program prepare, transfer, and integrate emerging adults into the adult care setting from a pediatric setting;
2. The extent to which emergency department providers are adequately trained and otherwise prepared to treat and manage sickle cell patients presenting with vaso-occlusive crises including but not limited to the extent to which providers follow clinically validated algorithms and protocols regarding such treatment and management;
3. The extent to which sickle cell patients covered under the state Medicaid program are entitled to receive the same standard of care when referred or transferred to an out-of-state facility, and the extent to which the state reimburses such patients for reasonable interstate travel costs; and
4. Any additional areas identified by the Authority that impact the care and treatment of individuals in this state living with sickle cell disease or sickle cell trait.
C. When conducting the annual review required by this section, the Authority shall solicit and consider input from the general public, with specific emphasis on seeking input from persons or groups with knowledge and experience in the area of sickle cell disease treatment.
D. To the extent practicable, the Authority shall utilize the Oklahoma State Health Information Network and Exchange created under Section 1-133 of Title 63 of the Oklahoma Statutes to collect information for the purpose of implementing this section.
E. On or before January 15, 2023, and on or before January 15 each year thereafter, the Authority shall submit a report to the President Pro Tempore of the Senate and the Speaker of the House of Representatives for distribution to the appropriate subject matter committees that details the Authority's findings from the annual review required by this section and any recommendations to the Legislature based upon those findings. The Authority shall publish the annual report required by this subsection to its website in a manner accessible by the general public.
Added by Laws 2022, c. 162, § 1, eff. Nov. 1, 2022.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5028.1. Request for information for care coordination models for newborns through children 18 years of age.

A. The Oklahoma Health Care Authority, with assistance from the Department of Human Services and the Department of Mental Health and Substance Abuse Services, shall initiate a request for information for care coordination models for newborns through children eighteen (18) years of age in the custody of the Department of Human Services.
B. Any request for information shall require consideration of and incorporate efforts to continue the implementation of relevant initiatives as provided by the Master Settlement Agreement ("Pinnacle Plan") and administered by the Department of Human Services.
C. The Oklahoma Health Care Authority, with assistance from the Department of Human Services and the Department of Mental Health and Substance Abuse Services, shall provide a summary of the request for information responses to the President Pro Tempore of the Oklahoma State Senate, the Speaker of the Oklahoma House of Representatives and the Governor on or before January 1, 2018.
D. The Oklahoma Health Care Authority Board shall promulgate rules to implement the provisions of this section.
Added by Laws 2017, c. 208, § 1, eff. Nov. 1, 2017.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5029. Mailing information to victims of domestic violence.

A. The Oklahoma Health Care Authority shall coordinate with domestic violence sexual assault programs certified by the Office of the Attorney General who provide counseling services for victims of domestic violence to ensure that any information relating to billing or explanation of benefits (EOB) provided, maintained, monitored or otherwise handled by the Authority or any other state agency including, but not limited to, services rendered by such facilities, is not sent by paper mail to the actual physical address of persons receiving such services.
B. The Oklahoma Health Care Authority Board shall promulgate rules to implement the provisions of this act.
Added by Laws 2015, c. 324, § 1, eff. Nov. 1, 2015.
NOTE: Editorially renumbered from § 5028 of this title to avoid duplication in numbering.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5030.2. Definitions.

As used in Sections 1 through 5 of this act:
1. “Compendia” means the “American Hospital Formulary Services Drug Information”, “U.S. Pharmacopoeia Drug Information”, peer-reviewed medical literature, other information provided by individuals involved in health care, and information as needed by the Medicaid Drug Utilization Review Board;
2. “Criteria” means those explicit and predetermined elements that are used to assess or measure drug use on an ongoing basis to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes;
3. “Authority” means the Oklahoma Health Care Authority;
4. “Drug-disease contraindication” means the possibility that the therapeutic effect of a drug would be adversely altered by the presence of another disease or condition;
5. “Drug interactions” means the possibility that two or more drugs taken by a patient may lead to clinically significant toxicity that is uncharacteristic of any one of the drugs present or that the taking of which leads to interference with the effectiveness of one or any of the drugs;
6. “Drug to drug interaction” means a clinically significant adverse medical effect that results from the use of two or more drugs together;
7. “Drug Utilization Review” or “DUR” means both retrospective and prospective drug utilization review designed to educate physicians and pharmacists and thereby ensure that prescriptions are appropriate, medically necessary and not likely to have adverse medical results;
8. “Overutilization” or “underutilization” means the use of a drug in such quantities that the desired therapeutic goal is not achieved;
9. “Prospective drug utilization review” means the part of a drug utilization review program that occurs before a drug is dispensed, and that is designed to screen, based on explicit and predetermined criteria and standards, for potential drug therapy problems, including, but not limited to:
a.
therapeutic duplication,
b.
drug-disease contraindications,
c.
incorrect drug dosage or duration of drug treatment,
d.
drug allergy interactions, and
e.
clinical abuse or misuse; and
10. “Retrospective drug utilization review” means the part of the drug utilization review program that assesses or measures drug use based on an historical review of drug use data against predetermined and explicit criteria and standards on an ongoing basis with professional input. Retrospective drug utilization review includes the periodic examination of Medicaid drug pharmacy claims data and other information sources to identify the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care:
a.
among physicians, pharmacists, and patients, or
b.
associated with specific drugs.
Added by Laws 1999, c. 201, § 2, eff. July 1, 1999.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5030.3. Powers and duties of board.

A. The Medicaid Drug Utilization Review Board shall have the power and duty to:
1. Advise and make recommendations regarding rules promulgated by the Oklahoma Health Care Authority Board to implement the provisions of this act;
2. Oversee the development, implementation and assessment of a Medicaid retrospective and prospective drug utilization review program, including making recommendations regarding contractual agreements of the Oklahoma Health Care Authority with any entity involved in processing and reviewing Medicaid drug profiles for the drug utilization review program in accordance with the provisions of this act;
3. Develop and apply the criteria and standards to be used in retrospective and prospective drug utilization review. The criteria and standards shall be based on the compendia and federal Food and Drug Act approved labeling, and shall be developed with professional input;
4. Provide a period for public comment on each meeting agenda. As necessary, the Medicaid Drug Utilization Review Board may include a public hearing as part of a meeting agenda to solicit public comment regarding proposed changes in the prior authorization program and the retrospective and prospective drug utilization review processes. Notice of proposed changes to the prior authorization status of a drug or drugs shall be included in the monthly meeting agenda at least thirty (30) days prior to the consideration or recommendation of any proposed changes in prior authorization by the Medicaid Drug Utilization Review Board;
5. Establish provisions to timely reassess and, as necessary, revise the retrospective and prospective drug utilization review process;
6. Make recommendations regarding the prior authorization of prescription drugs pursuant to the provisions of Section 5 of this act; and
7. Provide members of the provider community with educational opportunities related to the clinical appropriateness of prescription drugs.
B. Any party aggrieved by a decision of the Oklahoma Health Care Authority Board or the Administrator of the Oklahoma Health Care Authority, pursuant to a recommendation of the Medicaid Drug Utilization Review Board, shall be entitled to an administrative hearing before the Oklahoma Health Care Authority Board pursuant to the provisions of the Administrative Procedures Act.
Added by Laws 1999, c. 201, § 3, eff. July 1, 1999.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5030.4. Drug utilization review program.

1. The Medicaid Drug Utilization Review Board shall develop and recommend to the Oklahoma Health Care Authority Board a retrospective and prospective drug utilization review program for medical outpatient drugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.
2. The retrospective and prospective drug utilization review program shall be operated under guidelines established by the Medicaid Drug Utilization Review Board as follows:
a.
The retrospective drug utilization review program shall be based on guidelines established by the Medicaid Drug Utilization Review Board using the mechanized drug claims processing and information retrieval system to analyze claims data in order to:
(1)
identify patterns of fraud, abuse, gross overuse or underuse, and inappropriate or medically unnecessary care,
(2)
assess data on drug use against explicit predetermined standards that are based on the compendia and other sources for the purpose of monitoring:
(a)
therapeutic appropriateness,
(b)
overutilization or underutilization,
(c)
appropriate use of generic drugs,
(d)
therapeutic duplication,
(e)
drug-disease contraindications
(f)
drug-drug interactions,
(g)
incorrect drug dosage,
(h)
duration of drug treatment, and
(i)
clinical abuse or misuse, and
(3)
introduce remedial strategies in order to improve the quality of care and to conserve program funds or personal expenditures.
b.
(1)
The prospective drug utilization review program shall be based on guidelines established by the Medicaid Drug Utilization Review Board and shall provide that, before a prescription is filled or delivered, a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from:
(a)
therapeutic duplication,
(b)
drug-drug interactions,
(c)
incorrect drug dosage or duration of drug treatment,
(d)
drug-allergy interactions, and
(e)
clinical abuse or misuse.
(2)
In conducting the prospective drug utilization review, a pharmacist may not alter the prescribed outpatient drug therapy without the consent of the prescribing physician or purchaser.
Added by Laws 1999, c. 201, § 4, eff. July 1, 1999.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5030.4A. Disease state management programs – Feasibility study.

A. The Oklahoma Health Care Authority shall study the feasibility of implementing one or more disease state management programs.
B. The components of the study shall include, but not be limited to:
1. A description and assessment of the findings, costs of the program, savings incurred and estimated costs and savings of an expansion of the pilot program for asthma disease state management developed by the Authority;
2. An overview of disease state management programs for enrollees of health management organizations contracting with the Authority pursuant to the Sooner Care Plus Program;
3. An assessment of the adaptability of such disease state management programs for the Medicaid fee-for-service population;
4. An overview of representative vendors of the disease state management programs, including their characteristics, capabilities and charges for products and services;
5. An overview and assessment of the disease state management pilot project developed by the Oklahoma State Education Employees Government Insurance Board; and
6. A record, if available, of the savings generated by disease state management programs in other states by pharmaceutical manufacturers for Medicaid fee-for-service recipients.
C. The study shall be under the joint direction of the Disease State Management Director and the Pharmacy Director of the Oklahoma Health Care Authority. The Directors shall consult with the following entities as they deem necessary:
1. Medical, pharmacy, and nursing professionals who are experienced in disease state management programs;
2. Appropriate pharmaceutical manufacturers in connection with study components outlined in paragraphs 4 and 5 of subsection B of this section;
3. Disease state management vendors; and
4. Other resources as necessary including, but not limited to, health care advocates.
D. The Oklahoma Health Care Authority shall submit periodic progress reports to the Joint Legislative Oversight Committee. The Oklahoma Health Care Authority shall publish and submit a final report by December 1, 2002, to the Speaker of the Oklahoma House of Representatives, the President Pro Tempore of the Senate, the Governor, and the chair of the Health and Social Services Subcommittee of the Appropriation and Budget Committee of the Oklahoma House of Representatives and of the Health and Social Services Subcommittee of the Committee on Appropriations of the Oklahoma State Senate.
E. As used in this section, "disease state management program" means an integrated system of interventions, measurements and refinements of health care delivery that include:
1. Patient education and involvement in self-care techniques;
2. Clinical policies/best practices that extend across the entire continuum of care;
3. Outpatient drug management;
4. Clinical information systems with the capacity to identify, classify, and track defined patient populations;
5. Informed support of physicians;
6. Team-oriented multidisciplinary approach; and
7. Feedback or continuous review.
Added by Laws 2002, c. 411, § 1, emerg. eff. June 5, 2002.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5051.2. Right to reimbursement for medical services - Assignment to Oklahoma Health Care Authority.

A. Whenever the Oklahoma Health Care Authority pays for medical services or renders medical services, for or on behalf of a person who has been injured or suffered an illness or disease, the right of the provider of the services to reimbursement shall be automatically assigned to the Oklahoma Health Care Authority, upon notice to the insurer or other party obligated as a matter of law or agreement to reimburse the provider on behalf of the patient.
B. Upon the assignment, the Authority, for purposes of the claim for reimbursement, becomes a provider of medical services.
C. The assignment of the right to reimbursement shall be applied and considered valid against any employer or insurer under the Workers' Compensation Act in this state.
D. Each insurer, upon receiving a claim from the Oklahoma Health Care Authority, shall accept the state’s right of recovery, to process and, if appropriate, pay the claim to the same extent that the plan would have been liable if it had been billed at the point of sale or by the original provider of services. Insurer shall not deny the Authority claims on the basis of the date of submission, the format of the claim, or for failure to present proper documentation of coverage at the point of sale.
E. Insurer shall make appropriate payments to the Authority as long as the claim is submitted for consideration within three (3) years from the date the service was furnished. Any action by the Authority to enforce the payment of the claim shall be commenced within six (6) years of the submission of the claim by the Authority.
Added by Laws 1981, c. 159, § 2, emerg. eff. May 8, 1981. Amended by Laws 1996, c. 221, § 2, eff. Nov. 1, 1996. Renumbered from § 200a of Title 56 by Laws 1996, c. 221, § 6, eff. Nov. 1, 1996. Amended by Laws 2007, c. 74, § 2, eff. Nov. 1, 2007.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5051.4. Coverage under Medicaid Program Reform Act of 2003 - Enrollment fee and/or premium.

The Oklahoma Health Care Authority is hereby authorized to charge an enrollment fee and/or premium for the provision of health care coverage under the Oklahoma Medicaid Program Reform Act of 2003. Such charges, if unpaid, create a debt to the state and are subject to recovery by the Authority by any legal action against an enrollee, the heirs or next of kin of the enrollee in the event of the death of the enrollee. The Authority may end coverage for the nonpayment of such enrollment and/or premium pursuant to rules promulgated by the Oklahoma Health Care Authority Board.
Added by Laws 2003, c. 464, § 11, eff. July 1, 2003.
2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-5051.5. Data files comparisons - File systems maintained by insurers - Exchange of information with Authority.

A. 1. On or after November 1, 2003, any entity that provides health insurance in this state including, but not limited to, a licensed insurance company, not-for-profit hospital service, medical indemnity corporation, managed care organization, self-insured plan, pharmacy benefit manager or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service is hereby required to compare data from its files with data in files provided to the entity by the Oklahoma Health Care Authority and accept the Authority’s right of recovery and the assignment of rights and not charge the Authority or any of its authorized agents any fees for the processing of claims or eligibility requests. Data files requested by or provided to the Authority shall provide the Authority with eligibility and coverage information that will enable the Authority to determine the existence of third party coverage for Medicaid recipients and the necessary information to determine during what period Medicaid recipients may be or may have been covered by the health insurer and the nature of the coverage that is or was provided, including the name, address, and identifying number of the plan.
2. The insurer shall transmit to the Authority, in a manner prescribed by the Centers for Medicare and Medicaid Services or as agreed between insurer and the Authority, an electronic file of all identified subscribers or policyholders, or their dependents, for whom there is data corresponding to the information contained in subsection C of this section.
B. 1. An insurer shall comply with a request under the provisions of this subsection no later than sixty (60) days after the date of transmission by the Authority and shall only be required to provide the Authority with the information required by subsection C of this section.
2. The Authority may make such request for data from an insurer no more than once every six (6) months, as determined by the date of the Authority’s original request.
C. Each insurer shall maintain a file system containing the name, address, group policy number, coverage type, social security number, and date of birth of each subscriber or policyholder, and each dependent of the subscriber or policyholder covered by the insurer, including policy effective and termination dates, claim submission address, and employer’s mailing address.
D. The Oklahoma Health Care Authority Board shall promulgate rules governing the exchange of information under this section. Such rules shall be consistent with all laws relating to the confidentiality or privacy of personal information or medical records including, but not limited to, provisions under the federal Health Insurance Portability and Accountability Act (HIPAA).
Added by Laws 2003, c. 464, § 12, eff. July 1, 2003. Amended by Laws 2007, c. 74, § 3, eff. Nov. 1, 2007; Laws 2011, c. 204, § 1, eff. Nov. 1, 2011.