1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 HOUSE BILL 3862 By: Ford
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6 AS INTRODUCED
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7 An Act relating to health insurance; defining terms;
7 providing for disclosure and review of prior
8 authorization requirements; providing who shall make
8 adverse determinations; providing for personnel
9 qualifications; requiring consultations prior to
9 adverse determinations; providing requirements for
10 certain physicians; providing for retrospective
10 denial; providing for exemptions; providing for
11 failure to comply; providing for codification; and
11 providing an effective date.
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15 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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16 SECTION 1. NEW LAW A new section of law to be codified
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17 in the Oklahoma Statutes as Section 6570.1 of Title 36, unless there
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18 is created a duplication in numbering, reads as follows:
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19 As used in this section:
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20 1. "Prior authorization" means the process by which utilization
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21 review entities determine the medical necessity and/or medical
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22 appropriateness of otherwise covered health care services prior to
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23 the rendering of such health care services. Prior authorization
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24 also includes any health insurer's or utilization review entity's
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 1 requirement that an enrollee or health care provider notify the
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2 health insurer or utilization review entity prior to providing a
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3 health care service; and
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4 2. "Utilization review entity" means an individual or entity
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5 that performs prior authorization for an:
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6 a. insurer that writes health insurance policies, and
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7 b. a preferred provider organization, health maintenance
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8 organization, or exclusive provider organization.
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9 SECTION 2. NEW LAW A new section of law to be codified
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10 in the Oklahoma Statutes as Section 6570.2 of Title 36, unless there
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11 is created a duplication in numbering, reads as follows:
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12 A. A utilization review entity shall make any current prior
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13 authorization requirements and restrictions readily accessible on
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14 its website to enrollees, health care professionals, and the general
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15 public. This includes the written clinical criteria. Requirements
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16 shall be described in detail but also in easily understandable
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17 language.
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18 B. If a utilization review entity intends either to implement a
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19 new prior authorization requirement or restriction or amend an
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20 existing requirement or restriction, the utilization review entity
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21 shall ensure that the new or amended requirement is not implemented
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22 unless the utilization review entity's website has been updated to
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23 reflect the new or amended requirement or restriction.
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 1 C. If a utilization review entity intends either to implement a
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2 new prior authorization requirement or restriction or amend an
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3 existing requirement or restriction, the utilization review entity
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4 shall provide health care providers of enrollees written notice of
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5 the new or amended requirement or amendment no less than sixty (60)
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6 days before the requirement or restriction is implemented.
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7 SECTION 3. NEW LAW A new section of law to be codified
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8 in the Oklahoma Statutes as Section 6570.3 of Title 36, unless there
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9 is created a duplication in numbering, reads as follows:
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10 A. A utilization review entity must ensure that all adverse
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11 determinations are made by a physician.
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12 1. The physician must:
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13 a. possess a current and valid non-restricted license to
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14 practice medicine in the state of Oklahoma,
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15 b. be of the same specialty as the physician who
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16 typically manages the medical condition or disease or
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17 provides the health care service involved in the
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18 request,
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19 c. have experience treating patients with the medical
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20 condition or disease for which the health care service
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21 is being requested, and
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22 d. make the adverse determination under the clinical
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23 direction of one of the utilization review entity's
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24 medical directors who is responsible for the provision
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 1 of health care services provided to enrollees of
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2 Oklahoma.
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3 SECTION 4. NEW LAW A new section of law to be codified
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4 in the Oklahoma Statutes as Section 6570.4 of Title 36, unless there
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5 is created a duplication in numbering, reads as follows:
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6 If a utilization review entity is questioning the medical
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7 necessity of a health care service, the utilization review entity
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8 must notify the enrollee's physician that medical necessity is being
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9 questioned. Prior to issuing an adverse determination, the
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10 enrollee's physician must have the opportunity to discuss the
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11 medical necessity of the health care service on the telephone with
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12 the physician who will be responsible for determining authorization
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13 of the health care service under review.
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14 SECTION 5. NEW LAW A new section of law to be codified
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15 in the Oklahoma Statutes as Section 6570.5 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. A utilization review entity must ensure that all appeals are
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18 reviewed by a physician.
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19 1. The physician must:
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20 a. possess a current and valid non-restricted license to
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21 practice medicine in Oklahoma,
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22 b. be currently in active practice in the same or similar
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23 specialty as a physician who typically manages the
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 1 medical condition or disease for at least five (5)
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2 consecutive years,
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3 c. be knowledgeable of, and have experience providing,
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4 the health care services under appeal,
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5 d. not be employed by a utilization review entity or be
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6 under contract with the utilization review entity
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7 other than to participate in one or more of the
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8 utilization review entity's health care provider
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9 networks or to perform reviews of appeals, or
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10 otherwise have any financial interest in the outcome
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11 of the appeal,
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12 e. not have been directly involved in making the adverse
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13 determination, and
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14 f. consider all known clinical aspects of the health
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15 care, service under review, including, but not limited
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16 to, a review of all pertinent medical records provided
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17 to the utilization review entity by the enrollee's
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18 health care provider, any relevant records provided to
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19 the utilization review entity by a health care
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20 facility, and any medical literature provided to the
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21 utilization review entity by the health care provider.
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22 SECTION 6. 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 A. A utilization review entity may not revoke, limit, condition
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2 or restrict a prior authorization if care is provided within forty-
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3 five (45) business days from the date the health care provider
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4 received the prior authorization.
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5 B. In the case of preventive care that has prior authorization
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6 approval, if it has been determined medically necessary by the
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7 medical provider that additional preventive care is needed, it shall
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8 be covered under the initial pre-authorization. For any
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9 subsequently provided preventive care covered by the initial pre-
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10 authorization, it must be in connection to care furnished by the
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11 medical provider. Any care provided to an enrollee that is not in
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12 connection to pre-authorized preventive care shall need to receive
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13 pre-authorization approval.
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14 C. Nothing in this section shall be construed to require pre-
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15 authorization approval of care that is already exempted from a pre-
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16 authorization approval.
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17 SECTION 7. NEW LAW A new section of law to be codified
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18 in the Oklahoma Statutes as Section 6570.7 of Title 36, unless there
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19 is created a duplication in numbering, reads as follows:
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20 A. A utilization review entity may not require a health care
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21 provider to complete a prior authorization for a health care service
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22 in order for the enrollee to whom the service is being provided to
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23 receive coverage if in the most recent 12-month period, the
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24 utilization review entity has approved or would have approved not
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 1 less than eighty percent (80%) of the prior authorization requests
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2 submitted by the health care provider for that health care service.
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3 B. A utilization review entity may evaluate whether a health
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4 care provider continues to qualify for exemptions as described in
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5 subsection A not more than once every twelve (12) months. Nothing
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6 in this section requires a utilization review entity to evaluate an
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7 existing exemption or prevents a utilization review entity from
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8 establishing a longer exemption period.
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9 C. A health care provider is not required to request an
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10 exemption in order to qualify for an exemption.
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11 D. A health care provider who does not receive an exemption may
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12 request from the utilization review entity at any time, but not more
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13 than once per year per service, evidence to support the utilization
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14 review entity's decision. A health care provider may appeal a
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15 utilization review entity's decision to deny an exemption.
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16 E. A utilization review entity may only revoke an exemption at
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17 the end of the 12-month period if the utilization review entity:
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18 1. Makes a determination that the health care provider would
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19 not have met the eighty percent (80%) approval criteria based on a
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20 retrospective review of the claims for the particular service for
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21 which the exemption applies for the previous three (3) months, or
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22 for a longer period if needed to reach a minimum of ten (10) claims
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23 for review;
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 1 2. Provides the health care provider with the information it
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2 relied upon in making its determination to revoke the exemption; and
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3 3. Provides the health care provider a plain language
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4 explanation of how to appeal the decision.
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5 F. An exemption remains in effect until the 30th day after the
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6 date the utilization review entity notifies the health care provider
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7 of its determination to revoke the exemption, or if the health care
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8 provider appeals the determination, the fifth day after the
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9 revocation is upheld on appeal.
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10 G. A determination to revoke or deny an exemption must be made
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11 by a health care provider licensed in Oklahoma of the same or
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12 similar specialty as the health care provider being considered for
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13 an exemption and have experience in providing the service for which
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14 the potential exemption applies.
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15 H. A utilization review entity must provide a health care
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16 provider that receives an exemption a notice that includes:
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17 1. A statement that the health care provider qualifies for an
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18 exemption from pre-authorization requirements;
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19 2. A list of services for which the exemptions apply; and
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20 3. A statement of the duration of the exemption.
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21 I. A utilization review entity shall not deny or reduce payment
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22 for a health care service exempted from a prior authorization
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23 requirement under this section, including a health care service
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24 performed or supervised by another health care provider when the
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 1 health care provider who ordered such service received a prior
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2 authorization exemption, unless the rendering health care provider:
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3 1. Knowingly and materially misrepresented the health care
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4 service in request for payment submitted to the utilization review
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5 entity with the specific intent to deceive and obtain an unlawful
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6 payment from utilization review entity; or
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7 2. Failed to substantially perform the health care service.
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8 SECTION 8. NEW LAW A new section of law to be codified
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9 in the Oklahoma Statutes as Section 6570.8 of Title 36, unless there
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10 is created a duplication in numbering, reads as follows:
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11 Any failure by a utilization review entity to comply with the
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12 deadlines and other requirements specified in this act will result
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13 in any health care services subject to review to be automatically
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14 deemed authorized by the utilization review entity.
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15 SECTION 9. This act shall become effective November 1, 2024.
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17 59-2-9667 TJ 01/09/24
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