2022 Oklahoma Statutes
Title 56. Poor Persons
§56-4002.8. Uniform procedures for review and appeal for adverse determinations.
A. A contracted entity shall utilize uniform procedures established by the Authority under subsection B of this section for the review and appeal of any adverse determination by the contracted entity sought by any enrollee or provider adversely affected by such determination.
B. The Authority shall develop procedures for enrollees or providers to seek review by the contracted entity of any adverse determination made by the contracted entity. A provider shall have six (6) months from the receipt of a claim denial to file an appeal. With respect to appeals of adverse determinations made by a contracted entity on the basis of medical necessity, the following requirements shall apply:
1. Medical review staff of the contracted entity shall be licensed or credentialed health care clinicians with relevant clinical training or experience; and
2. All contracted entities shall use medical review staff for such appeals and shall not use any automated claim review software or other automated functionality for such appeals.
C. Upon receipt of notice from the contracted entity that the adverse determination has been upheld on appeal, the enrollee or provider may request a fair hearing from the Authority. The Authority shall develop procedures for fair hearings in accordance with 42 C.F.R., Part 431.
Added by Laws 2021, c. 542, § 8, eff. Sept. 1, 2021. Amended by Laws 2022, c. 395, § 12, eff. July 1, 2022.
