2014 Oklahoma Statutes
Title 36. Insurance
§36-6538.1. Case manager or managers - Bidding criteria - Period of service - Duties - Payment and financial incentives.

This section is due to be repealed effective Jan. 1, 2017, by Laws 2014, c. 389, § 3.

A. The Board of Directors of the Health Insurance High Risk Pool shall select a case manager or managers through a competitive bidding process, to provide case management services for the Pool. The Board shall evaluate the bids submitted under this subsection based on criteria established by the Board, which criteria shall include, but not be limited to, the following:

1. The case manager or managers' proven ability to handle large group accident and health insurance case management and its understanding of health care delivery systems;

2. The cost savings attributed to the case manager or managers' services; and

3. An estimate of total charges for providing case management services to the Pool.

B. The case manager or managers shall serve for a period of up to five (5) years beginning January 1, 2009. Prior to the expiration of each contract period of service by a case manager, the Board shall invite all reasonably interested potential case managers, including the current case manager or managers, to submit bids to serve as a case manager for the succeeding contract period. The selection of the case manager or managers for the succeeding contract period shall be made at least four (4) months prior to the end of the current contract period. The Board may terminate the service of a case manager at any time if the Board determines that the case manager has failed to perform the duties effectively according to the contract established or for other good cause as determined by the Board. In this case, the Board will accept bids from other potential case managers to serve the remainder of the vacated term.

C. A case manager's duties shall include:

1. Assessing, planning, implementing, coordinating, monitoring and evaluating the options and services required to meet a member's health needs;

2. Performance of utilization review, to include concurrent review of inpatient skilled and rehabilitation services, emergency room retrospective review for appropriateness, frequency, and/or chronic disease indicators;

3. Authorization processes based upon nationally recognized criteria for elective inpatient and outpatient services;

4. Multidisciplinary complex case management for high risk pregnancy, transplants, neonates, and other complex cases; and

5. Providing other cost-containment measures as adopted by the Board.

D. 1. The case manager shall be paid, as provided in the contract of the Pool, for direct and indirect expenses incurred in providing case management service for the Pool.

2. As used in this subsection, the term "direct and indirect expenses" includes the portion of the printing expenses, case management expenses, management expenses, building overhead expenses and other actual operating and administrative expenses of the case manager which are approved by the Board as allocable to case management of the plan and included in the bid specifications.

E. The Pool may provide financial incentives to the case manager or managers based upon savings and outcomes attributed to such case manager or managers.

F. All information and data relating to the Pool which is collected, created or received by the case manager during the course of its contractual engagement with the Pool shall be the property of the Pool.

Added by Laws 2002, c. 439, § 6, eff. July 1, 2002. Amended by Laws 2008, c. 404, § 5, emerg. eff. June 3, 2008.