reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-41 - Membership

Current through Vol. 41, No. 20, July 1, 2024
(a) An HMO shall not expel or refuse to
				  re-enroll any enrollee, nor refuse to enroll individual members of a group, or
				  establish rules for eligibility that are based on health status factors, health
				  care needs, or age of the enrollee or individual.
(b) An HMO shall not require an individual
				  within a group to pay a higher premium or contribution than would a similarly
				  situated individual, based on a health-status factor.
(c) Nothing in this Section prohibits an HMO
				  from requiring that, as a condition of continued eligibility for enrollment,
				  dependents of a subscriber, upon reaching a specified age, convert to non-group
				  enrollment.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-42 - Individual conversion contracts

Current through Vol. 41, No. 20,
				  July 1, 2024
An HMO shall not be required to offer or issue any new
					 individual conversion contract to a subscriber or his or her enrolled
					 dependents.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-43 - Premiums/co-payments

Current through Vol. 41, No. 20, July 1, 2024
(a) Each HMO shall provide or arrange basic
				  health care services for a basic health care services payment which:
(1) Is paid on a periodic basis without
				  regard to the dates these services are provided;
(2) Is fixed without regard to the frequency,
				  extent, or kind of basic health care services furnished;
(3) Is fixed under a rating system which
				  generates funds sufficient to meet the HMO's financial plan, and under which
				  the rates are reasonable for the health services provided; and
(4) May be supplemented by nominal
				  co-payments for specific basic health care services. Each HMO may establish one
				  or more co-payment options calculated on the basis of a rating system.
(A) An HMO may not impose co-payment charges
				  that exceed fifty (50) percent of the total cost of providing any single
				  service to its enrollees, or in the aggregate more than :
(i) forty-five (45) percent of the total cost
				  of providing all basic health care services; or
(ii) the dollar amounts in effect under
				  section 223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for self-only and
				  family coverage, respectively, for taxable years beginning in 2014.
(B) An HMO shall not impose on any
				  subscriber or enrollee, in any calendar year, co-payment charges of more than
				  two hundred (200) percent of the annual premium charged for an option with no
				  co-payments.
(C) Co-payments
				  applied to a service must be equal for all providers unless the unequal
				  co-payments are based on differences in the cost to the HMO for the
				  service.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-44 - Internal grievance system

Current through Vol. 41, No. 20, July
				  1, 2024
A grievance system shall be established and maintained by
					 an HMO to provide reasonable procedures for the prompt and effective resolution
					 of written grievances pursuant to the HMO Act.
(1) An HMO shall provide grievance forms to
				  be given to enrollees who wish to register written grievances. Such forms shall
				  include the address and telephone number to which grievances must be directed
				  and shall also specify required time limits imposed by the HMO.
(2) The grievance system shall provide for
				  written acknowledgement of any grievance within seven (7) days from the date
				  the grievance is registered with the HMO. Each grievance shall be resolved or
				  finally determined within one hundred twenty (120) days after the grievance is
				  registered. This period may be extended in the event of a delay in obtaining
				  the documents or records from a non-contracting provider necessary for the
				  resolution of the grievance, or by the mutual written agreement of the HMO and
				  the enrollee.
(3) An enrollee or
				  any other person may seek the assistance of the Insurance Commissioner at any
				  time whether or not a written grievance is submitted to an HMO by an
				  enrollee.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04; Amended at 23 Ok
					 Reg 2758, eff 7-14-06
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-45 - Guaranteed renewal

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Except as
				  otherwise provided in this section, an HMO that issues a group contract must
				  renew or continue in force such coverage at the option of the
				  contractholder.
(b) An HMO may
				  nonrenew or discontinue a group contract based only on one or more of the
				  following conditions:
(1) The contractholder
				  has failed to pay premiums or contributions in accordance with the terms of the
				  contract or the HMO has not received timely premium payments.
(2) The contractholder has performed an act
				  or practice that constitutes fraud or made an intentional misrepresentation of
				  material fact under the terms of the contract.
(3) The contractholder has failed to comply
				  with a material provision of their group contract with the HMO that relates to
				  rules for employer contributions or group participation.
(4) The HMO is ceasing to offer a particular
				  type of coverage in a market.
(5)
				  There are no longer enrollees who live or work in the service area.
(6) In the case of group health coverage that
				  is made available only through a bona fide association, the membership of an
				  employer in the association, on the basis of which the coverage is provided,
				  ceases, but only if such coverage is terminated uniformly without regard to any
				  health-status-related factors that relate to any covered individuals.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-46 - Small group offering

Current through Vol. 41, No. 20, July
				  1, 2024
An HMO shall accept every small group employer and every
					 eligible individual of that employer that applies for coverage in accordance
					 with the Oklahoma Small Employer Health Insurance Reform Act, 36 O.S. §
										6511, et
					 seq.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 9 - HMO REQUIREMENTS AND PROHIBITIONS › Section 365:40-5-47 - Special enrollment periods

Current through Vol. 41, No. 20,
				  July 1, 2024
(a) An HMO
				  that issues a group contract shall permit an employee who is eligible, but not
				  enrolled, for coverage under the terms of the contract, or a dependent of such
				  an employee if the dependent is eligible but not enrolled for coverage under
				  such contract, to enroll for coverage under the terms of the contract if each
				  of the following conditions is met:
(1) The
				  employee or dependent was covered under a group health plan or had health
				  insurance coverage at the time coverage was previously offered to the employee
				  or dependent. For the purpose of this section, the terms "group health plan"
				  and "health insurance coverage" have the same meaning ascribed in Section 2791
				  of the Federal Public Health Service Act;
(2) The employee stated in writing at such
				  time that coverage under a group health plan or health insurance coverage was
				  the reason for declining enrollment, but only if the plan sponsor or HMO, if
				  applicable, required such a statement at such time and provided the employee
				  with notice of such requirement and the consequences of such requirement at
				  such time;
(3) The employee's or
				  dependent's coverage described in paragraph (1) above:
(A) Was under a COBRA continuation provision
				  or other continuation and the coverage under such provision was exhausted;
				  or
(B) Was not under such a
				  provision and the coverage was terminated as a result of loss of eligibility
				  for the coverage, including legal separation, divorce, death, termination of
				  employment, or reduction in the number of hours of employment, or the coverage
				  was terminated as a result of the termination of employer contributions toward
				  such coverage; and
(4)
				  Under the terms of the plan, the employee requests such enrollment not later
				  than thirty (30) days after the date in O.A.C. 365:40-5-47(a)(3)(A) or O.A.C.
				  365:40-5-47(a)(3)(B) occurred.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-50 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this subchapter is to permit, but not
					 require, plans to include a coordination of benefits (COB) provision unless
					 prohibited by federal law; to establish a uniform order of benefit
					 determination under which plans, including HMOs, pay claims; and to avoid claim
					 delays and misunderstandings that could otherwise result from the use of
					 inconsistent or incompatible provisions amount Plans. It is contrary to the
					 public policy of this state for a Plan to declare its coverage to be "excess"
					 to all others, or always "secondary", or to reduce its benefits because of the
					 existence of duplicate coverage in a manner other than as permitted by this
					 regulation; or to reduce its benefits because a person covered by the Plan is
					 eligible for any other coverage. It is requested that courts give effect to
					 this public policy when they consider the interrelation of Plans with order of
					 benefit determination rules which comply with this subchapter and Plans with
					 order of benefit determination rules which differ from those set forth in this
					 subchapter.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-52 - Effect on benefits

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Determining benefits.
This section shall apply in determining the
				  benefits as to a person covered under the Plan for any claim determination
				  period if, for the allowable expense incurred as to such person during such
				  period, the sum of:
(1) the benefits that
				  would be payable under this Plan in the absence of this provision,
				  and
(2) the benefits that would be
				  payable under all other Plans in the absence therein of provisions of similar
				  purpose to this provision would exceed such Allowable Expenses.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-53 - Right to receive and release necessary information

Current
				  through Vol. 41, No. 20, July 1, 2024
For the purpose of determining the applicability of and
					 implementing the terms of this section of this Plan or any provision of similar
					 purpose of any other Plan, the insurer or service plan may, without the consent
					 of or notice to any person, release to or obtain from any other insurance
					 company or other organization or person any information, with respect to any
					 person, which the insurer or service plan deems to be necessary for such
					 purposes. Any person claiming benefits under this plan shall furnish to the
					 insurer or service plan such information as may be necessary to implement this
					 section. Occasionally this will necessitate a carrier making payment as the
					 primary carrier with a right of recovery in the event that subsequent
					 investigation proves that payment as a secondary carrier should have been
					 made.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-54 - Benefit payments

Current through Vol. 41, No. 20, July 1,
				  2024
Carriers shall use the following claims administration
					 procedures to expedite claim payments where COB is involved:
(1)
Improving exchange of benefit
				  information.
(A) There should be
				  continued and improved education of claim personnel stressing accurate and
				  prompt completion of the HIC Duplicate Coverage Inquiry (DUP-1) Form by the
				  inquiring carrier and the responding carrier. This education effort should also
				  be encouraged through local claim associations. An HMO may use a form
				  substantially similar to the HIC Duplicate Coverage Inquiry (DUP-1) Form if
				  approved by the Insurance Commissioner prior to its use.
(B) Claim personnel should be encouraged to
				  make every effort, including use of the telephone, to speed up exchange of COB
				  information. All carriers shall respond to inquiries at least thirty (30) days
				  from receipt of such inquiries.
(C)
				  Carriers should encourage building a local date file of other group plans in
				  the area, with at least basic information on group health plans for major
				  employers.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-55 - Subrogation

Current through Vol. 41, No. 20, July 1, 2024
The concept of coordination of benefits is clearly
					 distinguishable from that of subrogation. Provisions for either may be included
					 in a group health insurance policy without compelling the inclusion or
					 exclusion of the other.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-56 - Small claim waivers

Current through Vol. 41, No. 20, July 1,
				  2024
Carriers shall waive the investigation of possible other
					 coverage for COB purposes on claims less than fifty dollars ($50), but if
					 additional liability is incurred to raise the small claim above fifty dollars
					 ($50), the entire liability may be included in the COB
					 computation.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-57 - Public education

Current through Vol. 41, No. 20, July 1,
				  2024
Each carrier has an affirmative obligation to urge its
					 respective group policyholder-clients to take reasonable steps to assure that
					 those insured by the group policy or subscriber contract have been exposed to
					 reasonably concise explanations, with as little technical terminology as is
					 commensurate with accuracy, as to the purpose and operation of COB. Such
					 educational effort may take the form of articles in the company magazines or
					 newspapers, speeches before the appropriate labor organization in the case of a
					 unionized company, brochures added to pay envelopes, notices on the company
					 bulletin board, material used by personnel department in counseling employees,
					 and the like.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-58 - Applicability

Current through Vol. 41, No. 20, July 1, 2024
(a) Group policies or contracts which are in
				  force at the time of promulgation of this subchapter which contain an "excess"
				  clause, "anti-duplication" provision, or any other provision by whatever name
				  designated under which benefits would be reduced because of other existing
				  coverages, other than the COB provisions established in this subchapter, shall
				  be brought into compliance by the later of the next anniversary or renewal date
				  of the group policy or contract or the expiration of the applicable
				  collectively bargained contract, pursuant to which they are written, if
				  any.
(b) The definition of "Plan"
				  in Section 51 of this Subchapter applies to plans that are delivered, issued
				  for delivery, or renewed on or after January 1, 2016. A contract that is in
				  force on January 1, 2016, must be brought into compliance with the definition
				  of "Plan" on the next anniversary date or renewal date of the contract, or the
				  expiration of any applicable collective bargaining contract under which it was
				  written.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-59 - Facility of payment

Current through Vol. 41, No. 20, July 1,
				  2024
Whenever payments which should have been made under this
					 Plan in accordance with this section have been made under any other Plans, the
					 insurer or service plan shall have the right, exercisable alone and in its sole
					 discretion, to pay over to any organizations making such other payments any
					 amounts it shall determine to be warranted in order to satisfy the intent of
					 this section, and amounts so paid shall be deemed to be benefits paid under
					 this Plan and, to the extent of such payments, the insurer or service plan
					 shall be fully discharged from liability under this Plan.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 11 - COORDINATION OF BENEFITS › Section 365:40-5-60 - Right of recovery

Current through Vol. 41, No. 20, July 1,
				  2024
Whenever payment has been made by the insurer with respect
					 to allowable expenses in a total amount, at any time, in excess of the maximum
					 amount of payment necessary at that time to satisfy the intent of this section,
					 the insurer or service plan shall have the right to recover such payments, to
					 the extent of such excess, from among one or more of the following, as the
					 insurer or service plan shall determine:
(1) any persons to or for or with respect to
				  whom such payments were made;
(2)
				  any other insurers; or
(3) service
				  plans or any other organizations.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 13 - TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS › Section 365:40-5-70 - Termination of group or individual contracts

Current through Vol.
				  41, No. 20, July 1, 2024
(a) An HMO desiring to either terminate or
				  not renew a group or individual contract shall provide at least sixty (60) days
				  advance notice of termination. Except, an HMO may terminate or not renew a
				  contract with less than sixty (60) days notice for cause such as failure to pay
				  premiums or fraud.
(b) A group
				  contract or individual contract shall not be terminated except as described in
				  Part 15 of this Subchapter and O.A.C.
				  365:40-5-45.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 13 - TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS › Section 365:40-5-71 - Termination of providers

Current through Vol. 41, No. 20, July 1,
				  2024
An HMO shall implement a policy governing termination of
					 providers. The policy shall include at least:
(1) Provisions for at least ninety (90) days
				  advance notice of contract termination by either the HMO or the provider, with
				  additional provisions for contract termination by the HMO with less than ninety
				  (90) days notice for cause;
(2)
				  Methods by which the termination policy shall be made known to providers and
				  members at the time of enrollment and on a periodic basis;
(3) Written notification to each member at
				  least thirty (30) days prior to the termination or withdrawal of a member's
				  primary physician from the HMO's provider network and of any other physician or
				  provider currently treating the member. The Department may waive the 30-day
				  prior notice requirement if the HMO demonstrates that immediate termination is
				  necessary for the protection of health, safety and welfare of members, or if
				  the HMO demonstrates that the provider has not complied with the termination
				  requirements under the contract; and
(4) Assurance of continued coverage of
				  services, under certain conditions, consistent with the following:
(A) Every plan shall establish procedures
				  governing termination of a participating provider who is terminated for reasons
				  other than cause. The procedures shall include assurance of continued coverage
				  of services, at the contract terms and price by a terminated provider for up to
				  ninety (90) calendar days from the date of notice to the covered person for a
				  covered person who:
(i) Has a degenerative and
				  disabling condition or disease;
(ii) Has entered the third trimester of
				  pregnancy. Additional coverage of services by the terminated provider shall
				  continue through at lest six (6) weeks of postpartum evaluation; or
(iii) Is terminally ill.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 13 - TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS › Section 365:40-5-72 - Continuation of benefits

Current through Vol. 41, No. 20, July 1,
				  2024
(a) If group or
				  individual contracts are terminated by the HMO, provision shall be made for
				  continuation of benefits to enrollees who, on the date of termination, are
				  confined in an inpatient facility until their discharge or expiration of
				  benefits according to the group or individual contract, and provision shall be
				  made for pregnant enrollees through delivery and discharge. An HMO is not
				  required to continue further benefits for an enrollee or group terminated for
				  cause.
(b) Each HMO shall have a
				  plan for handling insolvency that allows for continuation of benefits for the
				  duration of the contract period for which premiums have been paid, continuation
				  of benefits for enrollees who are confined on the date of insolvency in an
				  inpatient facility until their discharge or expiration of benefits, and
				  continuation of benefits for pregnant enrollees through delivery and discharge.
				  The Department shall require the plan to include one or more of the following:
(1) Insurance to cover the expenses to be
				  paid for continued benefits after the HMO's insolvency;
(2) Provisions in provider contracts that
				  obligate the provider to provide services for the duration of the period after
				  the HMO's insolvency for which premium payment has been made and until the
				  enrollees' discharge from inpatient facilities;
(3) Insolvency reserves;
(4) Acceptable letters of credit;
				  and
(5) Any other arrangements to
				  assure that benefits are continued as specified above.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 13 - TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS › Section 365:40-5-73 - Disenrollment for cause

Current through Vol. 41, No. 20, July 1,
				  2024
An HMO may disenroll an individual member of a group for
					 cause such as failure to pay premiums or copayments, fraud, or misuse of
					 identification card or if the enrollee's behavior is abusive, disruptive,
					 threatening, or uncooperative to the extent that continued membership in the
					 HMO seriously impairs the HMO's ability to furnish services to either the
					 enrollee or other enrollees. Before disenrolling the enrollee, the HMO
					 shall:
(1) Make a serious effort to
				  resolve the problem presented by the enrollee, including the use or attempted
				  use of the HMO's grievance procedures;
(2) Ascertain that the enrollee's behavior
				  does not directly result from an existing medical condition; and
(3) Document the problems, efforts, and
				  medical conditions that demonstrate the HMO's conformity to this
				  section.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 13 - TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS › Section 365:40-5-74 - Certification of creditable coverage [REVOKED]

Current through Vol.
				  41, No. 20, July 1, 2024
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 15 - DISCONTINUATION OF HMO › Section 365:40-5-80 - Notice

Current through Vol. 41, No. 20, July 1, 2024
An HMO shall give the Department at least one hundred
					 eighty (180) days written notice of any decision to cease doing business. The
					 HMO must submit for the Department's approval all notices, press releases,
					 conversion agreements, memorandums of understanding, or other marketing or
					 informational materials prior to their release and effective
					 dates.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 15 - DISCONTINUATION OF HMO › Section 365:40-5-81 - Individual market

Current through Vol. 41, No. 20, July 1,
				  2024
(a) If an HMO
				  elects to discontinue offering a particular contract form for health coverage
				  offered in the individual market, coverage under such form shall be
				  discontinued only if:
(1) The HMO provides
				  notice to the Department and to each covered individual provided coverage under
				  this contract form of such discontinuation at least ninety (90) days prior to
				  the date of the discontinuation of such coverage;
(2) The HMO offers to each individual
				  provided coverage under this contract form the option to purchase any other
				  individual health coverage currently being offered by the HMO for individuals
				  in such market in the state; and
(3) In exercising the option to discontinue
				  coverage of this contract form and in offering the option of coverage under
				  subparagraph (b)(2),1 the HMO acts uniformly without regard to any
				  health-status-related factor of enrolled individuals or individuals who may
				  become eligible for such coverage.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 15 - DISCONTINUATION OF HMO › Section 365:40-5-82 - Group market

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An HMO may
				  discontinue offering a particular contract form of group health coverage
				  offered in the small-group market or large-group market only if:
(1) The HMO provides notice to the Department
				  and to each contractholder provided coverage under this form in such market,
				  and to participants and beneficiaries covered under such coverage, of such
				  discontinuation at least ninety (90) days prior to the date of the
				  discontinuation of such coverage;
(2) The HMO offers to each contractholder
				  provided coverage under this form in such market the option to purchase any
				  other health coverage currently being offered by the HMO in such market;
				  and
(3) In exercising the option to
				  discontinue coverage of this form and in offering the option of coverage under
				  subparagraph (a)(2) above, the HMO acts uniformly without regard to the claims
				  experience of those contractholders or any health-status-related factor that
				  relates to any participants or beneficiaries covered or new participants or
				  beneficiaries who may become eligible for such coverage.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 15 - DISCONTINUATION OF HMO › Section 365:40-5-83 - Market reentry

Current through Vol. 41, No. 20, July 1,
				  2024
In the case of a discontinuation in the group or individual
					 markets, the HMO may not provide for the issuance of any group or individual
					 health coverage in this state during the 5-year period beginning on the date of
					 the discontinuation of the last health coverage not renewed.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 17 - CONFIDENTIALITY OF MEDICAL INFORMATION AND LIABILITY › Section 365:40-5-90 - Responsibility of HMO

Current through Vol. 41, No. 20, July 1,
				  2024
(a) The HMO shall
				  protect the confidentiality of its enrollees from public disclosure of
				  confidential and medical information, however, this shall not be construed to
				  prevent the Department or other legally constituted agencies of the State or
				  Federal Government or peer review organizations from completing medical record
				  reviews or obtaining information as required under applicable laws or
				  rules.
(b) The HMO shall have
				  access to treatment records and other information pertaining to the diagnosis,
				  treatment or health status of any enrollee.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 19 - REQUEST FOR ASSISTANCE AND PROMPT PAY FORMS › Section 365:40-5-100 - Request for assistance

Current through Vol. 41, No. 20, July
				  1, 2024
(a) The
				  Department shall expeditiously advise an HMO of each inquiry the Department
				  receives regarding that HMO. Such inquiries need not be handled through the
				  HMO's written grievance system.
(b)
				  The Department shall provide a form that an enrollee may use to request
				  assistance of the Department. The Department shall review such requests and
				  consider whether or not the request for assistance raises issues of compliance
				  with the HMO Act or the rules. If the Department has reason to believe that a
				  violation exists, then the matter shall be considered by the Department and a
				  determination shall be made by the Department as to the appropriate action to
				  be taken.
(c) The Department shall
				  not refer an inquiry or complaint to an HMO prior to investigating the matter
				  if the Department has reason to believe that referring the inquiry or complaint
				  may compromise the Department's ability to enforce the HMO Act or this
				  Chapter.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 19 - REQUEST FOR ASSISTANCE AND PROMPT PAY FORMS › Section 365:40-5-101 - Prompt Pay Form and requirements

Current through Vol. 41, No.
				  20, July 1, 2024
The Prompt Pay Form as set forth in Appendix G of this
					 Chapter shall be used in reporting violations of the prompt pay requirements.
					 The person filing the form shall submit the original form to the Consumer
					 Assistance and Claims Division of the Department and a copy to the entity
					 accused of the prompt pay violation named in the form.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 21 - GEOGRAPHIC SERVICE AREA VARIATIONS › Section 365:40-5-110 - Accessibility of providers

Current through Vol. 41, No. 20, July 1,
				  2024
(a) The Department
				  shall presume a proposed service area to be reasonable if the mean travel time
				  is thirty (30) minutes or less from six equidistant points on the area boundary
				  to the nearest primary and emergency care delivery sites within that
				  area.
(b) The Department shall
				  consider approving service areas with distances of greater than thirty (30)
				  minutes to primary and emergency care providers, based on the following.
(1) Primary or emergency care providers are
				  not available in the area;
(2)
				  Primary or emergency care providers are available but do not meet the HMO's
				  reasonable credentialing requirements;
(3) Primary or emergency care providers are
				  unwilling or unable to enter a reasonable health services contract with the
				  HMO; or
(4) Residents of the area
				  customarily travel longer than 30 minutes to reach primary or emergency care
				  providers.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 21 - GEOGRAPHIC SERVICE AREA VARIATIONS › Section 365:40-5-111 - Marketing and enrolling

Current through Vol. 41, No. 20, July 1,
				  2024
(a) All marketing,
				  enrollment, or informational materials produced by the HMO shall specify the
				  approved geographic service area within which contracting providers are
				  reasonably available and accessible.
(b) The Department recognizes that under some
				  circumstances, persons who neither live nor work in the service area desire to
				  enroll in an HMO. Those may include, but are not limited to, the following
				  persons.
(1) Retirees;
(2) Persons living or working at or near the
				  service area boundary, and whose neighbors are eligible for
				  enrollment;
(3) Employees who have
				  been relocated;
(4) Persons whose
				  best or only health coverage option is an HMO, despite the additional travel
				  time required;
(5) Persons who
				  customarily choose to travel to the service area for their health services;
				  or
(6) Family members living apart
				  from one another, as a result of circumstances such as legal separation or
				  divorce.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 21 - GEOGRAPHIC SERVICE AREA VARIATIONS › Section 365:40-5-112 - Geographic area filings

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Each HMO shall
				  describe its proposed service area in terms of political boundaries, zip codes,
				  or geographic boundaries.
(b) Each
				  HMO shall provide to the Department a map of the complete service area clearly
				  showing the service area boundaries, main traffic arteries, and any physical
				  barriers such as mountains and rivers. The HMO shall show on the map the
				  location of ambulatory and hospital providers. The HMO must mark six
				  equidistant points along the boundary, and calculate mean travel time from
				  those six points to the nearest primary and emergency services sites.
(c) The HMO shall provide the information
				  required in this Section in its license application filed pursuant to 36 O.S.
				  §
										6903.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-120 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Part is to ensure that claims for
					 payment or reimbursement shall be processed timely and that settlements shall
					 be paid in full and that prompt pay is received.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-121 - Requirement to reimburse claims for point of service

Current
				  through Vol. 41, No. 20, July 1, 2024
No HMO shall be required to reimburse claims for
					 non-authorized out-of-network services other than emergency services unless the
					 HMO offers a point of service option pursuant to Part 7 of this
					 Subchapter.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-122 - Responsibilities

Current through Vol. 41, No. 20, July 1, 2024
An HMO or its employees and agents shall not:
(1) Pay claims reviewers based on reductions,
				  unless the reductions are based on uniformly applied protocols designed to
				  detect billing errors and duplicate charges;
(2) Compel a subscriber or provider to:
(A) Accept less than the full settlement of a
				  claim; or
(B) File suit to obtain
				  full settlement; or
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-123 - Reimbursement criteria

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An HMO that
				  pays or reimburses claims shall disclose the criteria that establish how and
				  whether a claim for services delivered by a participating or non-participating
				  provider shall be paid. The disclosed criteria shall specify any documents
				  required to be filed with a claim.
(b) If an HMO requires providers to use a
				  uniform claim or billing form, the forms shall be either:
(1) The CMS-1500, or its successor, for
				  outpatient billing and claim submission; or
(2) The UB-92, or its successor, for hospital
				  billing and claim submission.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-124 - Claims payment report

Current through Vol. 41, No. 20, July
				  1, 2024
(a) Upon the
				  request of the Insurance Commissioner and in a time frame as specified by the
				  Insurance Commissioner, HMOs shall file with the Department a periodic report
				  on compliance with provisions in Titles 36 of the Oklahoma Statutes and this
				  Part regarding reimbursement of claims within certain time periods.
(b) Each report shall be accompanied by a
				  statement signed by a member of the Board of Directors or executive management
				  attesting to the accuracy of the report.
(c) Any HMO that delegates any claim payment
				  functions shall require the delegated entity or entities to prepare the
				  required report for claims the entity processes including the required
				  attestation.
(d) Each HMO shall
				  collect and submit all required report(s) as a complete package.
(e) These reports shall be in such form and
				  context as directed by the Department.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-125 - Elements of a clean claim

Current through Vol. 41, No. 20, July
				  1, 2024
(a)
Required clean claim elements.
A provider submits a clean claim by
				  providing the required data elements specified in O.A.C.
				  365:40-5-123
				  to an HMO along with any attachments and additional elements information of
				  which the provider has been properly notified pursuant to O.A.C.
				  365:40-5-126.
(b)
Attachments.
The Center for
				  Medicare and Medicaid Services has developed a variety of manuals that identify
				  various attachments required of different providers for specific services. An
				  HMO may use the appropriate Medicare standards for attachments in order to
				  properly process claims for certain types of services. An HMO shall only
				  require as attachments information that is either contained in or in the
				  process of being incorporated into a patient's medical or billing record
				  maintained by the provider. Before any attachments may be required, the HMO
				  shall satisfy the notification procedures set forth in O.A.C.
				  365:40-5-126.
(c)
Additional clean claim
				  elements.
Before any additional clean claim elements may be required,
				  the HMO shall satisfy the notification procedures set forth in O.A.C.
				  365:40-5-126.
				  An HMO shall only require as additional clean claim elements information that
				  is either contained in or in the process of being incorporated into a patient's
				  medical or billing record maintained by the provider.
Added at 21 Ok Reg 77,
					 eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff
					 7-14-04
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 40 - Health Maintenance Organization (HMO) › Subchapter 5 - Life, Accident & Health Division and Consumer Assistance and Claims Division Rules › Part 23 - REIMBURSEMENT OF CLAIMS › Section 365:40-5-126 - Disclosure requirements

Current through Vol. 41, No. 20, July 1,
				  2024
(a) An HMO shall
				  not require an attachment or an additional element unless it has given the
				  provider the disclosure mandated by this Section at least sixty (60) calendar
				  days before requiring the attachment or additional element as an element of the
				  clean claim.
(b) An HMO shall not
				  revise its requirements for data elements, attachments or additional elements
				  unless it has given the provider the disclosure mandated by this Section at
				  least sixty (60) calendar days before requiring the data element, attachment or
				  additional element.
(c) The HMO
				  shall not require claims filed during the sixty (60) day period after receipt
				  of the disclosure to include the required attachment or additional element
				  identified in the disclosure.
(d)
				  Methods of disclosure may include one or more of the following:
(1) A written notice to all affected
				  providers.
(2) Updated revisions to
				  the provider manual or other document that sets forth the claims filing
				  procedures; or
(3) Amendments to
				  provider contracts that specify clean claim elements.