2023 Oklahoma Statutes › Title 36. Insurance › §36-6475.5. External review.

A. 1. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to Section 6475.8, 6475.9, or 6475.10 of this title and include the appropriate statements and information set forth in subsection B of this section at the same time the health carrier sends written notice of:
a.
an adverse determination upon completion of the health carrier's utilization review process set forth in Sections 6551 through 6565 of this title, and
b.
a final adverse determination.
2. As part of the written notice required under paragraph 1 of this subsection, a health carrier shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Oklahoma Insurance Department."
3. The Insurance Commissioner may promulgate any necessary rule providing for the form and content of the notice required under this section.
B. 1. The health carrier shall include in the notice required under subsection A of this section:
a.
for a notice related to an adverse determination, a statement informing the covered person that:
(1)
if the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review to be conducted pursuant to Section 6475.10 of this title, or Section 6475.11 of this title if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, at the same time the covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination, but that the independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited review of the grievance prior to conducting the expedited external review, and
(2)
the covered person or the covered person's authorized representative may file a grievance under the health carrier's internal grievance process, but if the health carrier has not issued a written decision to the covered person or the covered person's authorized representative within thirty (30) days following the date the covered person or the covered person's authorized representative files the grievance with the health carrier and the covered person or the covered person's authorized representative has not requested or agreed to a delay, the covered person or the covered person's authorized representative may file a request for external review pursuant to Section 6475.6 of this title and shall be considered to have exhausted the health carrier's internal grievance process for purposes of Section 6475.7 of this title, and
b.
for a notice related to a final adverse determination, a statement informing the covered person that:
(1)
if the covered person has a medical condition where the time frame for completion of a standard external review pursuant to Section 6475.8 of this title would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review pursuant to Section 6475.9 of this title, or
(2)
if the final adverse determination concerns:
(a)
an admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or the covered person's authorized representative may request an expedited external review pursuant to Section 6475.9 of this title, or
(b)
a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or the covered person's authorized representative may file a request for a standard external review to be conducted pursuant to Section 6475.10 of this title or if the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or the covered person's authorized representative may request an expedited external review to be conducted under Section 6475.10 of this title.
2. In addition to the information to be provided pursuant to paragraph 1 of this subsection, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to Section 6475.17 of this title, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review.
3. As part of any forms provided under paragraph 2 of this subsection, the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 CFR, Section 164.508, by which the covered person, for purposes of conducting an external review under this act, authorizes the health carrier and the covered person's treating health care provider to disclose protected health information including medical records, concerning the covered person that are pertinent to the external review.
Added by Laws 2011, c. 278, § 39. Amended by Laws 2011, c. 360, § 29; Laws 2022, c. 154, § 12, eff. Nov. 1, 2022.