reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 17 - Restricted Acts, Prohibited Acts and Enforcement [Revoked] › Section 310:656-17-3 - Enforcement [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 19 - Reports, Periodic Filings and Records [Revoked] › Section 310:656-19-1 - Application changes [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 19 - Reports, Periodic Filings and Records [Revoked] › Section 310:656-19-2 - Periodic filings [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 19 - Reports, Periodic Filings and Records [Revoked] › Section 310:656-19-3 - Changes in contracts and marketing materials [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 19 - Reports, Periodic Filings and Records [Revoked] › Section 310:656-19-4 - Department review [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 656 - Managed Care and Utilization Review [Revoked] › Subchapter 19 - Reports, Periodic Filings and Records [Revoked] › Section 310:656-19-5 - Books and records [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 17 Ok Reg 2986,
				  eff 7-13-00; Revoked at 22 Ok Reg 1166, eff
				  5-26-05
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 1 - General Provisions › Section 310:657-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
This chapter provides for certification of the workplace
				  medical plan under three (3) laws. Those laws are 85 O.S. Supp. 1996, Section
				  14.3, 63 O.S. Supp. 1996, Sections 1-101 et seq. (Oklahoma Public Health Code),
				  and 75 O.S. Supp. 1996, Sections 250.1 through 323 (Administrative Procedures
				  Act).
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 1 - General Provisions › Section 310:657-1-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
				  shall have the following meaning, unless the context clearly indicates
				  otherwise:
"Act"
means the Workers' Compensation Act, Title
				  85 of the Oklahoma Statutes.
"Commissioner"
means the Commissioner of
				  Health.
"Department"
means the Oklahoma State Department
				  of Health.
"Facility"
means a licensed, certified or
				  accredited institution or health care setting which renders prescribed medical
				  or health care service.
"Health professional"
means an individual who is
				  licensed or otherwise authorized under applicable laws, rules or standards to
				  deliver medical or health services.
"Insurer"
means a self-insured employer, a group
				  self-insurance association plan, or an employer's workers' compensation
				  insurance carrier.
"Peer"
means a health professional who holds a
				  non-restricted license in Oklahoma or another state and practices a similar
				  specialty as typically manages the service under review.
"Person"
means an individual, partnership,
				  association, corporation, or other public or private legal entity including an
				  agency.
"Plan"
means a workplace medical plan.
"Provider"
means any health professional,
				  facility or other entity licensed or otherwise authorized under applicable
				  laws, rules or standards to furnish medical or health
				  service.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 1 - General Provisions › Section 310:657-1-3 - Severability

Current through Vol. 41, No. 20, July 1, 2024
If any subchapter or paragraph of OAC 310:657 shall be ruled
				  invalid, such judgment shall not affect any other subchapter or paragraph. The
				  remaining subchapters and paragraphs shall remain in full
				  force.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 3 - Provider Credentialing › Section 310:657-3-1 - General considerations

Current through Vol. 41, No. 20, July 1, 2024
The Plan's credentialing program shall ensure that each
				  provider is competent and qualified to offer medical or health services. A Plan
				  may use other criteria in deciding which of the properly credentialed providers
				  shall be selected to participate in the Plan.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 3 - Provider Credentialing › Section 310:657-3-2 - Credentialing responsibilities

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				Plan shall credential each provider under written policies, and shall complete
				credentialing before the provider's contract becomes effective. The Plan shall
				not list the provider in the provider directory or marketing materials until
				credentialed.
(b) The Plan shall
				establish a body of professional peers to review and approve the Plan's
				credentialing policies. A health professional designated by the Plan shall
				oversee credentialing.
(c) The Plan
				shall obtain proof of the applicant's current authority to practice a health
				profession. Proof shall be based on evidence from the source issuing the
				credential. The Plan shall retain all records and documents on a provider for
				at least five (5) years. Nothing in OAC 310:657-3 requires public disclosure of
				information which is confidential following applicable law.
(d) At least once every five (5) years, the
				Plan shall verify the professional's authority to practice.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 3 - Provider Credentialing › Section 310:657-3-3 - Provider review process

Current through Vol. 41, No. 20, July 1, 2024
(a) A
				provider who is subject to credentialing shall have the right to review all
				credentialing information obtained by the Plan, and to review the credentialing
				procedures.
(b) The Plan shall
				advise the provider of any information that does not meet the Plan's
				credentialing standards.
(c) Each
				Plan shall have an appeal process by which a provider may submit additional
				information and request further review.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 5 - Quality Assurance › Section 310:657-5-1 - Purpose and intent

Current through Vol. 41, No. 20, July 1, 2024
The Plan shall assure the quality of its services using, at
				  least, a system of quality assessment and quality improvement. The Plan shall
				  ensure that all providers participate in quality assurance
				  activities.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 5 - Quality Assurance › Section 310:657-5-2 - Quality assessment and quality improvement

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan, either directly or through
				contract, shall maintain a quality assessment and improvement system. The
				system shall have at least these features:
(1)
				Systematic collection and analysis of data, including measures of provider
				performance; and
(2) Activities to
				foster continuous improvement of services provided to injured workers,
				including:
(A) identifying practices which
				result in positive health outcomes; and
(B) integrating information sources such as
				service management, claims processing, worker satisfaction and
				grievances.
(3)
				Organizational support for the system with input from the medical
				director;
(4) Methods of evaluating
				performance improvement activities.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 5 - Quality Assurance › Section 310:657-5-3 - Reporting and disclosure requirements

Current through Vol. 41, No. 20, July 1, 2024
The Plan, either directly or through contract, shall document
				  and communicate information about quality assurance.
(1) In marketing materials the Plan shall
				include a summary of its quality assurance activities.
(2) The Plan shall make available to the
				employee, a description of its quality assurance process and a statement of
				employee rights in the Plan.
(3)
				The Plan shall share information with its regulatory agencies, providers and
				the public about its quality assurance activities and progress.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-1 - Purpose and intent

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan's
				utilization review program shall assist the manager in providing services to an
				individual injured worker and shall assist administrators in delivering
				services to all employees.
(b)
				Nothing in OAC 310:657-7 restrains a Plan or provider from supplying
				information to any person required by the Act.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-2 - Scope and content of utilization review

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan shall implement a utilization
				review program that describes all delegated and nondelegated review activities
				for covered services. The program shall include:
(1) Procedures to evaluate service need,
				appropriateness and efficiency, with processes to detect service underuse and
				overuse;
(2) Data sources and
				review criteria used to determine the need for, and appropriateness of, medical
				and health services;
(3) Processes
				for resolving disputes on medical or health services;
(4) Consistent application of criteria and
				decisions;
(5) Data collection and
				analytical methods that may be used to assess use of health care
				services;
(6) Provisions for
				ensuring confidentiality of information;
(7) Reports to the governing body or its
				designee; and
(8) Day-to-day
				program management.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-3 - Operational requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				utilization review program shall have criteria that are based on evidence and
				regularly evaluated.
(1) Practicing providers
				shall be involved in developing the review criteria.
(2) After refusing to authorize a service,
				the Plan shall provide the review criteria for that service upon request to
				affected providers, the injured worker, and the Commissioner.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-4 - Utilization review decision

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				Plan shall complete any individual decision to authorize or deny a
				non-emergency service within two (2) working days after obtaining all necessary
				information. Necessary information includes any clinical evaluation of an
				injured worker by a provider other than the one originally recommending a
				proposed service.
(b) The Plan
				shall notify the provider by telephone within twenty-four (24) hours after the
				decision to authorize or deny a service. The Plan shall send confirmation of
				the decision within two (2) working days after deciding.
(c) If the injured worker is an inpatient or
				undergoing treatment, the Plan shall communicate to the provider any decision
				to authorize or deny the service by telephone within twenty-four (24) hours
				after the decision. The Plan shall send confirmation to the provider within two
				(2) working days after deciding. A decision on an extended stay shall identify
				the additional number of days or services approved.
(d) A decision to authorize or deny coverage
				for an emergency service shall be based on the patient's presenting
				symptoms.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-5 - Denial of service

Current through Vol. 41, No. 20, July 1, 2024
(a) A decision to
				deny a service shall be clearly documented, including specific bases for the
				action. Confirmation shall be sent to the provider within two (2) working days
				after the decision. If the Plan is aware that the request for service was
				initiated by the injured worker, the Plan shall send written notice to the
				injured worker within two (2) working days after the decision.
(b) A decision to deny a service after the
				service has been provided to an injured worker shall be issued in writing
				within five (5) workings days after obtaining all necessary
				information.
(c) Written notice of
				a decision to deny a service shall describe the dispute resolution
				procedures.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-6 - Dispute resolution procedures

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				Plan shall have procedures for dispute resolution on issues related to medical
				care under the Plan. This procedure may be different than the grievance
				procedure for resolving matters not directly related to medical care under the
				Plan. A dispute resolution procedure shall be available to the injured worker
				and to the attending or ordering provider.
(b) The Plan's procedure shall be designed to
				resolve each dispute within ten (10) days after receipt, unless information is
				not available in the normal course of business.
(c) Each dispute shall be evaluated by an
				appropriate peer or another licensed health professional as mutually agreed by
				the parties. The evaluating professional shall not have been involved in the
				initial decision to deny a service.
(d) The Plan shall notify the injured worker
				and affected provider of its decision.
(e) An injury requiring emergency services
				shall be treated immediately, without regard for the ten (10) day dispute
				resolution period.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 7 - Utilization Review › Section 310:657-7-7 - Disclosure requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) In materials
				provided to insurers, insureds and employees, the Plan shall include a summary
				of its utilization review procedures.
(b) The Plan shall clearly disclose employee
				rights and responsibilities relating to quality assurance and utilization
				review.
(c) The Plan shall provide
				to employees a toll-free telephone number for information about the Plan's
				utilization review program.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 9 - Geographic Service Areas › Section 310:657-9-1 - Access to providers

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				Commissioner shall presume a proposed service area to be reasonable if the mean
				travel time is thirty (30) minutes or less from six (6) points on the area
				boundary to the nearest primary care delivery sites in that area, and sixty
				(60) minutes or less to specialty service providers.
(b) The Commissioner may approve a service
				area with travel times of greater than thirty (30) minutes to primary services,
				or sixty (60) minutes to specialty services, based on the following:
(1) Providers are not available in the
				area;
(2) Providers are available
				but do not meet the Plan's reasonable credentialing requirements;
(3) Providers are unwilling or unable to
				enter a reasonable health services contract with the Plan;
(4) Residents of the area customarily travel
				longer times to reach medical and health providers; or
(5) Providers have access to air ambulance
				services to transport injured workers.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 9 - Geographic Service Areas › Section 310:657-9-2 - Required filings

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan shall
				provide the information required in OAC 310:657-9 in its initial application.
				Before any change of the service area, the Plan shall file the revised
				information in an application to amend or renew the certificate. All marketing
				materials produced by the Plan shall specify the approved geographic service
				area.
(b) The Plan shall describe
				its proposed service area using zip codes or other geographic units.
(c) The Plan shall provide a map of the
				service area showing the area boundaries, main traffic arteries and physical
				barriers. The Plan shall show the locations of primary and specialty providers.
				The Plan shall mark six (6) points along the boundary. The Plan shall calculate
				mean travel time from those points to the nearest primary care service sites.
				The Plan also shall calculate the mean travel time from the six (6) points to
				the nearest specialty care service sites.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 9 - Geographic Service Areas › Section 310:657-9-3 - Access to services

Current through Vol. 41, No. 20, July 1, 2024
(a) Medical and
				health services shall be provided or arranged in the service area by the
				Plan.
(b) Services shall be
				available to the Plan's employees with reasonable promptness considering:
(1) Geographic location, hours of operation,
				and provisions for after-hours services; and
(2) Staffing patterns and types of
				providers.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 11 - Grievance System › Section 310:657-11-1 - Grievance system required

Current through Vol. 41, No. 20, July 1, 2024
Each Plan shall maintain a system to resolve
				  grievances.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 11 - Grievance System › Section 310:657-11-2 - Grievance forms

Current through Vol. 41, No. 20, July 1, 2024
A Plan shall provide a grievance form for any enrollee,
				  employer, insurer, insured or provider who wishes to file a written grievance.
				  The form shall include information about the grievance system to help the
				  person in completing and filing the form. Nothing in OAC 310:657 prevents a
				  Plan from using other methods, such as a toll-free telephone line, to correct
				  problems before the employee files a written grievance.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 11 - Grievance System › Section 310:657-11-3 - Time frames

Current through Vol. 41, No. 20, July 1, 2024
The grievance system shall require an initial response within
				  seven (7) days after a grievance is filed with the Plan. A grievance shall be
				  resolved or finally determined by the Plan within ninety (90) days after the
				  grievance is filed. This period may be extended if the Plan encounters a delay
				  in obtaining the documents or records necessary to reach a decision on the
				  grievance. The ninety (90) day time frame may be extended also by written
				  agreement between the Plan and the person filing the
				  grievance.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 11 - Grievance System › Section 310:657-11-4 - Effect of arbitration

Current through Vol. 41, No. 20, July 1, 2024
If a grievance may be resolved through arbitration, the
				  person filing the grievance shall be notified of the terms of arbitration. Any
				  Plan that makes binding arbitration a condition of a contract shall fully
				  disclose this requirement in the contract and in any
				  summaries.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 11 - Grievance System › Section 310:657-11-5 - Request for assistance

Current through Vol. 41, No. 20, July 1, 2024
The Commissioner shall provide a form which any person may
				  use to register dissatisfaction with the Plan. The Commissioner shall review
				  such filings and consider whether or not the Plan complies with the Act and OAC
				  310:657. If the Commissioner has no reason to believe that a Plan violated the
				  Act or OAC 310:657, the Plan's action shall be upheld. If the Commissioner has
				  reason to believe that a violation exists, then the Commissioner shall consider
				  the matter under 310:657-25.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 13 - Ownership and Control of a Plan › Section 310:657-13-1 - Ownership

Current through Vol. 41, No. 20, July 1, 2024
The Plan's ownership, control and management shall have the
				  knowledge, skills and experience that will make the Plan's operation beneficial
				  to employees. The Commissioner shall not grant or renew a certificate when the
				  Plan's ownership, control, or management is under the control of any person
				  whose operations are or have been marked by the following:
(1) business practice or conduct that is to
				the detriment of the public, stockholders, investors, or creditors;
				or
(2) improper manipulation of
				assets or accounts.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 13 - Ownership and Control of a Plan › Section 310:657-13-2 - Removal or transfer of property

Current through Vol. 41, No. 20, July 1, 2024
(a)
				No Plan shall remove its property or business from Oklahoma without the
				Commissioner's written approval.
(b) No Plan shall attempt to transfer its
				property or merge with any other person without first obtaining the
				Commissioner's written approval.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 13 - Ownership and Control of a Plan › Section 310:657-13-3 - Accounts, books and records

Current through Vol. 41, No. 20, July 1, 2024
Each Plan shall maintain proper accounting controls including
				  correct and complete records of accounts. Such records shall be available to
				  the Commissioner during normal business hours.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 13 - Ownership and Control of a Plan › Section 310:657-13-4 - Governing body oversight

Current through Vol. 41, No. 20, July 1, 2024
The Plan's governing body or its designee shall be
				  responsible for quality assurance, quality improvement, and utilization review
				  actions. The governing body or designee shall approve and regularly evaluate
				  these programs. If the Plan contracts with other entities to operate these
				  programs, then the governing body or designee may consider reports from those
				  entities instead of conducting its own evaluations. The governing body or
				  designee shall receive reports of quality assurance, quality improvement and
				  utilization review actions at least once every six (6)
				  months.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 13 - Ownership and Control of a Plan › Section 310:657-13-5 - Ownership and control safeguards

Current through Vol. 41, No. 20, July 1, 2024
The Plan shall safeguard the fairness and equity of medical
				  and health service delivery if an insurer or an insured:
(1) Directly participates in the Plan's
				formation or certification;
(2)
				Occupies a position as the Plan's director, governing member, officer, agent,
				or employee;
(3) Has any ownership,
				financial or investment interest in the Plan;
(4) Has any contract with the Plan that
				limits the Plan's ability to accept business from any other source;
				or
(5) Has any relationship with a
				Plan, other than a contract for provision of medical and health services under
				the Act.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-1 - Net worth requirement

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan's
				net worth shall be calculated as assets minus liabilities, plus fully
				subordinated debt.
(b) The Plan
				shall maintain a positive net worth and shall maintain working capital to meet
				its obligations as they become due.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-2 - Applicability

Current through Vol. 41, No. 20, July 1, 2024
The financial requirements in OAC
				  310:657-15-3
				  through OAC 310:657-15-10 shall apply to a Plan unless it demonstrates that a
				  requirement does not apply. To decide if a requirement applies, the
				  Commissioner shall consider the Plan's organizational structure, financial
				  arrangements, fiduciary responsibilities, accounting controls and risk sharing
				  arrangements.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-3 - Errors and omissions policy

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Each Plan shall file evidence of an errors and omissions policy to protect
				insurers, insureds and enrollees financially from the Plan's errors.
(1) The policy shall be no less than five
				hundred thousand dollars ($500,000) annual aggregate for all claims made during
				the policy period.
(2) The policy
				shall remain in force for at least two (2) years after certification
				ends.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-4 - Fidelity bond [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Revoked at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-5 - Preference of claims [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Revoked at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-6 - Liability insurance

Current through Vol. 41, No. 20, July 1, 2024
In addition to the errors and omissions insurance policy each
				  Plan shall have liability insurance coverage to protect the interests of
				  injured workers. The insurance may include excess or stop loss, medical
				  malpractice, and general liability coverage.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-7 - Provider contracts [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Revoked at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-8 - Projections

Current through Vol. 41, No. 20, July 1, 2024
(a) The Commissioner may require a Plan to
				submit updates of projections required by OAC
				310:657-21-4(1)(K).
				Each update shall explain any significant variance between operating results
				and previously forecast amounts.
(b) The Commissioner may request a revision
				of a financial projection that is inconsistent with the Plan's historic
				performance.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 15 - Financial Requirements › Section 310:657-15-9 - Impairment

Current through Vol. 41, No. 20, July 1, 2024
(a) A Plan with less than the minimum
				required net worth shall be considered an impaired Plan.
(b) The Commissioner shall determine the
				amount of impairment. The amount of impairment may be based on a financial
				statement made by a Plan or on an examination report. The Commissioner shall
				require the Plan to eliminate the impairment within ninety (90) days. If the
				Plan does not eliminate the impairment, the Commissioner may revoke the Plan's
				certificate.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this subchapter is to ensure that a Plan
				  furnishes to each insurer, insured, or provider a complete and understandable
				  copy of their agreement. The contract shall not contain unjust, unfair,
				  misleading or deceptive provisions.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-2 - Contents of the insurers' or insureds' contract

Current through Vol. 41, No. 20, July 1, 2024
Each contract shall contain a clear statement of the
				  following:
(1) Plan's name and
				address;
(2) Eligibility
				requirements;
(3) Medical and
				health services in the area;
(4)
				Emergency care services and procedures for authorizing emergency services by
				non-Plan providers;
(5) Out of area
				services;
(6) Limits and excluded
				items;
(7) Employee
				termination;
(8) Employee
				reinstatement;
(9) Claims
				procedures, if any;
(10) Dispute
				resolution and grievance procedures;
(11) Continuing coverage;
(12) Extension of benefits;
(13) Substitution of creditors;
(14) Geographic service area;
(15) Entire contract provision;
(16) Term of coverage;
(17) Renewing contract;
(18) Canceling contract;
(19) Reinstatement of contract;
(20) Grace period; and
(21) Conformity with state law.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-3 - Provider directory

Current through Vol. 41, No. 20, July 1, 2024
(a) The Plan shall
				ensure that each insurer or insured with which it contracts receives a copy of
				the directory of providers.
(b) The
				provider directory may be filed as part of the contract to satisfy the Plan's
				obligation to provide a statement of services, procedures and
				requirements.
(c) The provider
				directory shall not contain summaries, provisions or statements which are
				unfair, unjust, misleading or deceptive.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-4 - Commissioner review

Current through Vol. 41, No. 20, July 1, 2024
(a) No contract,
				provider directory or amendment shall be delivered or issued unless the
				Commissioner has approved its form.
(b) Each contract form shall be filed with
				the Commissioner at least thirty (30) days before delivery or issue. The
				Commissioner may extend the period for review for an additional thirty (30)
				days. The form is approved if the Commissioner takes no action at the end of
				the review period. The Plan shall notify the Commissioner in writing before
				using a form approved by the Commissioner's lack of action.
(c) After at least thirty (30) days notice,
				the Commissioner may withdraw approval of any form for cause shown.
(d) When a filing is disapproved or when
				approval is withdrawn, the Commissioner shall give the Plan written notice of
				the reasons for disapproval. The notice shall inform the Plan that within
				thirty (30) days after receipt of the notice the Plan may request a hearing.
				The hearing shall be conducted under the Administrative Procedures
				Act.
(e) The Commissioner may
				require supporting information in determining whether to approve or disapprove
				a filing.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-5 - Service changes

Current through Vol. 41, No. 20, July 1, 2024
Each Plan shall provide a notice of any service changes to
				  each insurer or insured with which it contracts. The notice shall identify the
				  proposed services which differ from the current services. Such notice shall be
				  provided at least thirty (30) days before the effective date of the
				  change.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok
				  Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff
				  6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 17 - Contracts and Service Explanations › Section 310:657-17-6 - Provider contracts

Current through Vol. 41, No. 20, July 1, 2024
(a) Each contract
				between a Plan and a participating provider shall be in writing. The contract
				shall state that an injured worker shall not owe any sums otherwise due from
				the Plan, insurer or insured under the contract.
(b) The contract shall set penalties against
				any provider who attempts to collect from an injured worker any sums owed by
				the Plan, insurer or insured under the contract.
(c) No participating provider, agent, trustee
				or assignee shall attempt to collect from an injured worker any sum owed by the
				Plan, insurer or insured under the contract.
Added at 23 Ok Reg 2404,
				  eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 19 - Confidentiality › Section 310:657-19-1 - Responsibility of Plan

Current through Vol. 41, No. 20, July 1, 2024
(a) Worker-specific
				injury information and provider-specific performance data are confidential and
				the Plan shall implement procedures to ensure that confidentiality. The
				procedures shall include:
(1) Safeguards to
				protect against unauthorized disclosure; and
(2) Provisions that any party making
				information available to the public is responsible for failure to comply with a
				standard of due care.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 19 - Confidentiality › Section 310:657-19-2 - Responsibility of Commissioner

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				Commissioner shall hold in confidence any information about an injured worker
				and the information shall not be disclosed to any person except under these
				circumstances:
(1) When necessary to
				administer OAC 310:657;
(2) Upon
				the written consent of the worker;
(3) Following law or court order for the
				production or discovery of evidence; or
(4) When a claim or dispute between the
				worker and the Plan makes such information pertinent.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 21 - Applying for a Certificate › Section 310:657-21-1 - Application required

Current through Vol. 41, No. 20, July 1, 2024
(a) Each Plan shall
				apply for a certificate on forms provided by the Commissioner.
(b) The person responsible for providing or
				arranging all required Plan services shall be the applicant for the
				certificate.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 21 - Applying for a Certificate › Section 310:657-21-2 - Deadlines for filing

Current through Vol. 41, No. 20, July 1, 2024
(a) The application
				shall be filed by the Plan and approved by the Department before beginning
				operations.
(b) The application
				shall be filed at least thirty (30) days before a transfer of ownership of an
				existing Plan.
(c) The Plan shall
				apply to renew the certificate every five (5) years. The application to renew a
				certificate shall be filed at least thirty (30)days before the certificate
				expires.
(d) The Commissioner shall
				notify the applicant of incomplete items within thirty (30) days after receipt
				of the application. The applicant shall provide additional information within
				ninety (90) days after receipt of the notice. Failure to submit the requested
				information shall result in dismissal of the application. The Commissioner and
				the applicant may mutually agree to extend the deadline up to ninety (90)
				days.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 21 - Applying for a Certificate › Section 310:657-21-3 - Where to file

Current through Vol. 41, No. 20, July 1, 2024
The application and the filing fee shall be delivered or
				  mailed to the Department. The effective date of filing shall be the date the
				  application and fee are received by the Department.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 23 - Approval or Denial of Application › Section 310:657-23-1 - Conditions for approval

Current through Vol. 41, No. 20, July 1, 2024
The Commissioner shall issue or renew a certificate when the
				  Commissioner finds that the Plan meets the requirements of the Act and OAC
				  310:657.
(1) Necessary medical and
				health services shall be provided by the Plan as guaranteed in the Plan's
				contracts with insurers and insureds and in the provider directory.
(A) These services shall be provided without
				bias for, or against, any type of provider.
(B) The Commissioner shall review services
				available considering employee population and characteristics, and locations
				and hours of providers.
(C) The
				Plan may offer necessary medical and health services directly, or may arrange
				services through contracts or arrangements with providers, or may both offer
				and arrange services.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 23 - Approval or Denial of Application › Section 310:657-23-2 - Duration of certificate

Current through Vol. 41, No. 20, July 1, 2024
The Commissioner may issue a certificate to a Plan for five
				  (5) years. The Commissioner may specify conditions on an initial certificate
				  which shall be satisfied before the Plan offers medical and health services to
				  employees.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok
				  Reg 2404, eff 6-25-06
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 23 - Approval or Denial of Application › Section 310:657-23-3 - Certificate transfer

Current through Vol. 41, No. 20, July 1, 2024
No certificate shall be issued to any person other than the
				  person making application. A certificate shall not be transferred in whole or
				  part to another person.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 23 - Approval or Denial of Application › Section 310:657-23-4 - Denial of Application

Current through Vol. 41, No. 20, July 1, 2024
(a) An
				application for certification may be denied for one (1) or more of the
				following:
(1) Failure to meet any of the
				standards in the Act or OAC 310:657; or
(2) Failure to provide timely additional
				information required under OAC
				310:657-21-2.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 23 - Approval or Denial of Application › Section 310:657-23-5 - Appeals

Current through Vol. 41, No. 20, July 1, 2024
Any party who disagrees with the Commissioner's decision to
				  deny the application may request a hearing, or may appeal directly to district
				  court as provided in the Administrative Procedures Act.
Added at 12 Ok Reg 2977,
				  eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff
				  6-13-96