Bill No. 1810, introduced by Representatives Newton and Gillespie, amends various sections of Oklahoma law concerning prior authorization and Medicaid services. The bill updates definitions within the "Ensuring Access to Medicaid Act," specifically changing the definition of "enrollee" to reference Section 6592 instead of the previously deleted Section 6592.1. It also broadens the definition of "Children's Specialty Plan" to include children involved in Family Centered Services cases and those in trial reunification plans. Additionally, the bill clarifies prior authorization requirements to align with the Ensuring Transparency in Prior Authorization Act, while removing specific timeframes for authorization determinations related to hospital transfers and non-hospitalized members, allowing the Oklahoma Health Care Authority to establish timely determination requirements.

Moreover, the bill eliminates previous mandates for determinations on requests for acute care inpatient services and other healthcare services to be made within twenty-four hours. Instead, it introduces a requirement for determinations on biomarker testing requests to comply with Section 4003. It also specifies that prior authorization is not needed for covered prescription drugs that do not require it by the Authority. The bill establishes new guidelines for the peer-to-peer review process after an adverse determination, ensuring that providers have a reasonable opportunity to participate in urgent cases within twenty-four hours. Additionally, it outlines requirements for internal and external reviews and appeals of adverse determinations, including detailed explanations for denials and uniform appeal rules across contracted entities. The effective dates for the various sections of the act are set for November 1, 2025, and July 1, 2026.

Statutes affected:
Introduced: 56-4002.6
Floor (House): 56-4002.6
Engrossed: 56-4002.2, 56-4002.6