1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 HOUSE BILL 3190 By: Newton
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6 AS INTRODUCED
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7 An Act relating to health insurance; creating the
7 Ensuring Transparency in Prior Authorization Act;
8 defining terms; requiring disclosure and review of
8 prior authorization; requiring certain personnel make
9 adverse determinations; requiring consultation prior
9 to adverse determination; requiring certain criteria
10 for reviewing physicians; establishing certain
10 obligations for utilization review entity in certain
11 circumstances; providing an exception for prior
11 authorization; prohibiting certain retrospective
12 denial; providing for length of prior authorization;
12 providing for length of prior authorization in
13 certain circumstances; providing continuity of care;
13 providing standard for transmission of authorization;
14 providing for failure to comply; providing for
14 severability; providing for noncodification;
15 providing for codification; and providing an
15 effective date.
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19 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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20 SECTION 1. NEW LAW A new section of law not to be
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21 codified in the Oklahoma Statutes reads as follows:
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22 This act may be known and cited as the "Ensuring Transparency in
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23 Prior Authorization Act."
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 1 SECTION 2. NEW LAW A new section of law to be codified
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2 in the Oklahoma Statutes as Section 6570.1 of Title 36, unless there
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3 is created a duplication in numbering, reads as follows:
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4 As used in this act:
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5 1. "Adverse determination" means a decision by a utilization
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6 review entity that the health care services furnished or proposed to
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7 be furnished to an enrollee are not medically necessary, or are
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8 experimental or investigational; and benefit coverage is therefore
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9 denied, reduced, or terminated. A decision to deny, reduce, or
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10 terminate services that are not covered for reasons other than their
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11 medical necessity or experimental or investigational nature is not
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12 an "adverse determination" for purposes of this act;
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13 2. "Authorization" means a determination by a utilization
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14 review entity that a health care service has been reviewed and,
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15 based on the information provided, satisfies the utilization review
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16 entity's requirements for medical necessity and appropriateness, and
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17 that payment will be made for that health care service;
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18 3. "Chronic condition" means a diagnosis of a disease dependent
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19 on duration, a condition lasting twelve (12) months or longer, and
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20 its effect on the patient based on one or both of the following
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21 criteria:
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22 a. the condition results in the need for ongoing
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23 intervention with medical products, treatment,
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24 services, and special equipment, or
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 1 b. the condition places limitations on self-care,
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2 independent living, and social interactions;
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3 4. "Clinical criteria" means the written policies, written
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4 screening procedures, drug formularies or lists of covered drugs,
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5 determination rules, determination abstracts, clinical protocols,
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6 practice guidelines, medical protocols and any other criteria or
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7 rationale used by the utilization review entity to determine the
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8 necessity and appropriateness of health care services;
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9 5. "Emergency health care services" means those health care
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10 services that are provided in an emergency facility after the sudden
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11 onset of a medical condition that manifests itself by symptoms of
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12 sufficient severity, including severe pain, that the absence of
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13 immediate medical attention could reasonably be expected by a
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14 prudent layperson, who possesses an average knowledge of health and
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15 medicine, to result in:
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16 a. placing the patient's health in serious jeopardy,
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17 b. serious impairment to bodily function, or
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18 c. serious dysfunction of any bodily organ or part;
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19 6. "Enrollee" means an individual eligible to receive health
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20 care service benefits from a health insurer pursuant to a health
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21 plan or other health insurance coverage. The term enrollee includes
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22 an enrollee's legally authorized representative;
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23 7. "Health care services" means health care procedures,
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24 treatments, or services:
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 1 a. provided by a facility licensed in Oklahoma, or
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2 b. provided by a doctor of medicine, a doctor of
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3 osteopathy, or within the scope of practice for which
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4 a health care professional is licensed in Oklahoma.
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5 The term "health care service" also includes the provision,
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6 administration or prescription of pharmaceutical products or
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7 services or durable medical equipment;
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8 8. "Medically necessary health care services" means health care
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9 services that a prudent physician would provide to a patient for the
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10 purpose of preventing, diagnosing or treating an illness, injury,
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11 disease or its symptoms in a manner that is:
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12 a. in accordance with generally accepted standards of
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13 medical practice,
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14 b. clinically appropriate in terms of type, frequency,
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15 extent, site, and duration, and,
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16 c. not primarily for the economic benefit of the health
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17 plans and purchasers or for the convenience of the
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18 patient, treating physician, or other health care
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19 provider;
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20 9. "Medication for opioid use disorder (MOUD)" means the use of
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21 medications, commonly in combination with counseling and behavioral
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22 therapies, to provide a comprehensive approach to the treatment of
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23 opioid use disorder. FDA-approved medications used to treat opioid
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24 addiction include methadone; buprenorphine, alone or in combination
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 1 with naloxone; and extended-release injectable naltrexone. Types of
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2 behavioral therapies include individual therapy, group counseling,
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3 family behavior therapy, motivational incentives, and other
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4 modalities;
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5 10. "NCPDP SCRIPT Standard" means the National Council for
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6 Prescription Drug Programs SCRIPT Standard Version 2017071, or the
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7 most recent standard adopted by the United States Department of
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8 Health and Human Services (HHS). Subsequently released versions of
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9 the NCPDP SCRIPT Standard may be used;
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10 11. "Notice" means communication delivered both electronically
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11 and through the United States Postal Service or common carrier;
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12 12. "Primary care provider" means a health care professional
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13 that works in family medicine, general internal medicine, or general
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14 pediatrics who provides definitive care to the undifferentiated
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15 patient at the point of first contact, and takes continuing
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16 responsibility for providing the patient's comprehensive care. This
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17 care may include chronic, preventive and acute care in both
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18 inpatient and outpatient settings;
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19 13. "Prior authorization" means the process by which
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20 utilization review entities determine the medical necessity and/or
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21 medical appropriateness of otherwise covered health care services
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22 prior to the rendering of such health care services. Prior
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23 authorization also includes any health insurer's or utilization
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24 review entity's requirement that an enrollee or health care provider
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 1 notify the health insurer or utilization review entity prior to
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2 providing a health care service;
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3 14. "Urgent health care service" means a health care service
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4 with respect to which the application of the time periods for making
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5 a non-expedited prior authorization, which, in the opinion of a
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6 physician with knowledge of the enrollee's medical condition:
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7 a. could seriously jeopardize the life or health of the
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8 enrollee or the ability of the enrollee to regain
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9 maximum function, or
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10 b. could subject the enrollee to severe pain that cannot
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11 be adequately managed without the care or treatment
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12 that is the subject of the utilization review.
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13 For the purpose of this act, urgent health care service shall
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14 include mental and behavioral health care services.
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15 15. "Utilization review entity" means an individual or entity
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16 that performs prior authorization for one or more of the following:
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17 a. an employer with employees in Oklahoma who are covered
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18 under a health benefit plan or health insurance
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19 policy,
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20 b. an insurer that writes health insurance policies,
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21 c. a preferred provider organization, or health
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22 maintenance organization, or
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23 d. any other individual or entity that provides, offers
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24 to provide, or administers hospital, outpatient,
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 1 medical, prescription drug, or other health benefits
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2 to a person treated by a health care professional in
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3 Oklahoma under a policy, plan or contract.
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4 SECTION 3. NEW LAW A new section of law to be codified
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5 in the Oklahoma Statutes as Section 6570.2 of Title 36, unless there
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6 is created a duplication in numbering, reads as follows:
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7 A utilization review entity shall make any current prior
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8 authorization requirements and restrictions readily accessible on
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9 its website to enrollees, health care professionals, and the general
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10 public. This includes the written clinical criteria. Requirements
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11 shall be described in detail but also in easily understandable
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12 language.
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13 1. If a utilization review entity intends either to implement a
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14 new prior authorization requirement or restriction, or amend an
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15 existing requirement or restriction, the utilization review entity
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16 shall ensure that the new or amended requirement is not implemented
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17 unless the utilization review entity's website has been updated to
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18 reflect the new or amended requirement or restriction.
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19 2. If a utilization review entity intends either to implement a
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20 new prior authorization requirement or restriction, or amend an
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21 existing requirement or restriction, the utilization review entity
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22 shall provide contracted health care providers or enrollees written
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23 notice of the new or amended requirement or amendment no less than
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 1 sixty (60) days before the requirement or restriction is
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2 implemented.
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3 3. Entities using prior authorization shall make statistics
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4 available regarding prior authorization approvals and denials on
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5 there website in a readily accessible format.
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6 They should include categories for:
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7 a. physician specialty,
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8 b. medication or diagnostic test/procedure,
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9 c. indication offered,
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10 d. reason for denial,
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11 e. if appealed,
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12 f. if approved or denied on appeal, and
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13 g. the time between submission and response.
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14 SECTION 4. NEW LAW A new section of law to be codified
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15 in the Oklahoma Statutes as Section 6570.3 of Title 36, unless there
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16 is created a duplication in numbering, reads as follows:
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17 A utilization review entity must ensure that all adverse
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18 determinations are made by a physician. The physician must:
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19 1. Possess a current and valid nonrestricted license to
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20 practice medicine in Oklahoma;
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21 2. Be of the same specialty as the physician who typically
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22 manages the medical condition or disease or provides the health care
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23 service involved in the request;
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 1 3. Have experience treating patients with the medical condition
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2 or disease for which the health care service is being requested; and
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3 4. Make the adverse determination under the clinical direction
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4 of one of the utilization review entity's medical directors who is
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5 responsible for the provision of health care services provided to
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6 enrollees of Oklahoma. All such medical directors must be
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7 physicians licensed in Oklahoma.
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8 SECTION 5. NEW LAW A new section of law to be codified
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9 in the Oklahoma Statutes as Section 6570.4 of Title 36, unless there
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10 is created a duplication in numbering, reads as follows:
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11 If a utilization review entity questions the medical necessity
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12 of a health care service, the utilization review entity must notify
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13 the enrollee's physician that medical necessity is being questioned.
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14 Prior to issuing an adverse determination, the enrollee's physician
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15 must have the opportunity to discuss the medical necessity of the
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16 health care service on the telephone with the physician who will be
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17 responsible for determining authorization of the health care service
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18 under review.
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19 SECTION 6. NEW LAW A new section of law to be codified
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20 in the Oklahoma Statutes as Section 6570.5 of Title 36, unless there
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21 is created a duplication in numbering, reads as follows:
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22 A utilization entity must ensure that all appeals are reviewed
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23 by a physician. The physician must:
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 1 1. Possess a current and valid nonrestricted license to
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2 practice medicine in Oklahoma;
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3 2. Be currently in active practice in the same or similar
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4 specialty as a physician who typically manages the medical condition
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5 or disease for at least five (5) consecutive years;
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6 3. Be knowledgeable of, and have experience providing, the
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7 health care services under appeal;
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8 4. Not be employed by a utilization review entity or be under
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9 contract with the utilization review entity other than to
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10 participate in one or more of the utilization review entity's health
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11 care provider networks or to perform reviews of appeals, or
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12 otherwise have any financial interest in the outcome of the appeal;
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13 5. Not have been directly involved in making the adverse
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14 determination; and
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15 6. Consider all known clinical aspects of the health care
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16 service under review, including but not limited to, a review of all
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17 pertinent medical records provided to the utilization review entity
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18 by the enrollee's health care provider, any relevant records
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19 provided to the utilization review entity by a health care facility,
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20 and any medical literature provided to the utilization review entity
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21 by the health care provider.
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22 SECTION 7. NEW LAW A new section of law to be codified
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23 in the Oklahoma Statutes as Section 6570.6 of Title 36, unless there
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24 is created a duplication in numbering, reads as follows:
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 1 If a utilization review entity requires prior authorization of a
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2 health care service, the utilization review