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53	53	STATE OF OKLAHOMA
54	54
55	55	1st Session of the 59th Legislature (2023)
56	56
57	57	SENATE BILL 441 By: Montgomery
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67	67	AS INTRODUCED
68	68
69	69	An Act relating to health insurance; defining terms;
70	70	allowing health benefit p lan to exempt certain health
71	71	care provider from cer tain preauthorization
72	72	requirement under certain circumstances; establishing
73	73	process for preauthorization exemption; requi ring
74	74	plan to publish certain criteria; requirin g plan to
75	75	provide notice to a provider under certain
76	76	circumstances; construing provision; establishing
77	77	denial process of certain exemption ; providing for
78	78	recission of certain exemption; establishin g appeal
79	79	process; authorizing provider to request an
80	80	independent review organization review appe al;
81	81	establishing appeal determination as binding;
82	82	prohibiting retroactivity; prohibiting plan from
83	83	denying or reducing certain payment to provider under
84	84	certain circumstance s; providing for codification;
85	85	and providing an effective date.
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93	93	BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
94	94	SECTION 1. NEW LAW A new section of law to be codified
95	95	in the Oklahoma Statutes as Section 6890 of Title 36, unless there
96	96	is created a duplication in numbering, reads as follows:
97	97
98	98
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148	148	A. For the purposes of this act:
149	149	1. “Health benefit plan” means a health benefit plan offered by
150	150	a Health Maintenance Organization (HMO) operating under the Health
151	151	Maintenance Organization Act of 2003 pursuant to Section 6901 et
152	152	seq. of Title 36 of the Oklahoma Statutes, including a contract
153	153	between a health benefit plan and a provider to pr ovide to a patient
154	154	proposed medically necessary and appr opriate health care services ,
155	155	and a health benefit plan offered by a Preferred Provider
156	156	Organization (PPO) as defined pursuant to Section 6054 of Title 36
157	157	of the Oklahoma Statutes;
158	158	2. “Health care provider ” or “provider” means a health care
159	159	provider as defined pursuant to Sect ion 6571 of Title 36 of the
160	160	Oklahoma Statutes;
161	161	3. “Health care service” means a service as defined pursuant to
162	162	Section 1219.6 of Title 36 of t he Oklahoma Statutes;
163	163	4. “Independent review organization ” means an independent
164	164	review organization as defined pursuant to Section 6475.3 of Title
165	165	36 of the Oklahoma Statutes; and
166	166	5. “Preauthorization” means a determination by a health benefit
167	167	plan, or person contracting with a health benefit plan, that a
168	168	health care service proposed to be provided to a patient is
169	169	medically necessary and appropriate.
170	170	B. A health benefit plan that uses a preauthorization process
171	171	for health care services may exempt a health care provider from
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223	223	obtaining preauthorizati on for a particular health care service. A
224	224	health benefit plan shall evaluate whether a provider qualifies for
225	225	an exemption from preauthorization requirements once every six (6)
226	226	months. The exemption shall be granted if, in the most recent six -
227	227	month evaluation period, the health benefit plan has ap proved or
228	228	would have approved not less than ninety percent (90%) of the
229	229	preauthorization requests submitted by the provider for the health
230	230	care service.
231	231	C. A health benefit plan may continue an exemption under this
232	232	subsection without evaluating whether the provider qualifies for an
233	233	exemption for a particular evaluation period. A provider is not
234	234	required to request an exemption from preauthorization to qualify
235	235	under this act.
236	236	D. 1. A health benefit plan tha t provides any preauthorization
237	237	exemption under this act shall post the criteria for such exempt ion
238	238	on a publicly available website and a monthly updated list of h ealth
239	239	care providers who fall under the exemption.
240	240	2. A health benefit plan shall provide notice to a provider
241	241	that is eligible for a prea uthorization exemption no later than five
242	242	(5) business days after the determination has been made. The notice
243	243	shall include:
244	244	a. a statement that the provider qualifies for an
245	245	exemption from preauthorizati on requirements,
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297	297	b. a list of health care services and health benefit
298	298	plans to which the exemption applies,
299	299	c. a statement of the duration of the exemption, and
300	300	d. a notification of the health benefit plan’s payment
301	301	requirements.
302	302	3. Nothing in this subsec tion shall be construed to authorize a
303	303	provider to provide a health care service outside of the scope of
304	304	the provider’s applicable license or to require a health benefi t
305	305	plan to pay for a health care service that is per formed in violation
306	306	of the laws of this state.
307	307	E. A health benefit plan may deny an ex emption from
308	308	preauthorization only if the provider does not have the exemption at
309	309	the time of the relevant evaluation period and if the health benefit
310	310	plan provides the provider with sufficient data for the relevant
311	311	preauthorization request period that dem onstrates that the provider
312	312	does not meet the criteria for the exemption.
313	313	F. If a provider is denied a preauthorizati on exemption or has
314	314	the exemption rescinded pursuan t to Section 2 of this act, the
315	315	provider is eligible for consideration of an exemption for the same
316	316	health care service immediately after the next evaluation period
317	317	concludes.
318	318	SECTION 2. NEW LAW A new section of law to be codified
319	319	in the Oklahoma Statutes as Section 6891 of Title 36, unless there
320	320	is created a duplication in numbering, reads as foll ows:
321	321
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372	372	A. A health benefit plan that complies with all other
373	373	provisions of this act may rescind a provider’s exemption from
374	374	preauthorization requirements only during January or June of each
375	375	year.
376	376	B. 1. A health benefit plan shall mak e the determination to
377	377	rescind an exemption by using a retrospective review process for the
378	378	most recent evaluation period. The review shall use a sample chosen
379	379	at random of not fewer than five (5) and no more than twenty (20)
380	380	claims submitted by the provider. If findings conclude that less
381	381	than ninety percent (90%) of the sampled claim s for the particular
382	382	health service met the criteria used to previously grant the
383	383	exemption, the recission process may commence.
384	384	2. For a determination to rescind a provider’s exemption, the
385	385	determination shall be made by an individual licensed to practice
386	386	medicine in this state w ho has the same or a similar specialty as
387	387	the provider under review.
388	388	3. A health benefit plan may only conduct a retrospective
389	389	review of a healthcare service subject to an exemption if:
390	390	a. the health benefit plan has a reasonable cause to
391	391	suspect a basis of denial exists under sub section A of
392	392	this section, or
393	393	b. a review is needed to determine if the provider
394	394	administering the exemption still qu alifies for an
395	395	exemption under this act; provided , however, this
396	396
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447	447	subparagraph shall not be construed to modify or
448	448	otherwise affect any other requirements placed upo n a
449	449	health benefit plan except those outlined in
450	450	subsection A of Section 3 of this act.
451	451	C. 1. A provider’s exemption from preauthorization
452	452	requirements under this section shall remain in effect until thi rty
453	453	(30) days after the health benefit plan not ifies the provider of the
454	454	determination to rescind the exemption if the provider does not
455	455	appeal the determination. The provider shall be notified not less
456	456	than twenty-five (25) days before the proposed recis sion is to take
457	457	effect. Notice shall include all r elevant data and information used
458	458	to make the determination including, but not limited t o, the sample
459	459	information from the relevant evaluation p eriod and shall include a
460	460	plain language explanation of the p rocedures for the provider to
461	461	appeal the determinat ion.
462	462	2. If the provider appeals the determination to rescind the
463	463	preauthorization exemp tion, the exemption shall remain in effect
464	464	until the fifth day after the date that an independent rev iew
465	465	organization affirms the determination to rescind the exemption .
466	466	D. A provider has the right to a review of a determination
467	467	regarding the recission of a preauthorization exemption which shall
468	468	be conducted by an independent review organiza tion. A health
469	469	benefit plan may not require any other internal appeal process
470	470	before a provider can request a review of the determination. In
471	471
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522	522	requesting a review, the provider may request that the independent
523	523	review organization consider a different random sample under the
524	524	same provisions of subsection B of this section.
525	525	E. 1. A health benefit plan is bound by an appeal or
526	526	independent review determination that does no t affirm the
527	527	determination made by the plan to rescind a preauthorization
528	528	exemption.
529	529	2. If a determination regardin g a preauthorization exemption
530	530	made by a health benefit plan is overturned by an independent review
531	531	organization pursuant to a review, the health benefit plan shall not
532	532	attempt to rescind the ex emption before the end of the next
533	533	evaluation period.
534	534	3. A health benefit plan may not retroactively deny a hea lth
535	535	care service because of a recission of an exemption under any
536	536	circumstance.
537	537	F. An independent review organization shall complete the revie w
538	538	of a determination regarding an exemption recission no later than
539	539	the thirtieth day after the date that a provider files the request
540	540	for a review under this section.
541	541	G. If a review of a determinatio n by a health benefit plan is
542	542	conducted pursuant to this section, the health benefit plan shall
543	543	pay a fee pursuant to Section 19 of Title 76 of the Oklahoma
544	544	Statutes to obtain access to patient medical records . The health
545	545
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596	596	benefit plan shall pay for the appeal or independent review of a n
597	597	adverse determination regarding the preauthorization exemption.
598	598	SECTION 3. NEW LAW A new section of law to be codified
599	599	in the Oklahoma Statut es as Section 6892 of Title 36, unless there
600	600	is created a duplication in numbering, reads as f ollows:
601	601	A health benefit plan shall not deny or reduce payment to a
602	602	health care provider for a health care service for which the
603	603	provider has been exempted from preauthorizatio n requirements under
604	604	Section 1 of this act unless the provider:
605	605	1. Knowingly or materially misrepresented the health care
606	606	service in a request for payment submitted to the health benefit
607	607	plan with the specific in tent to deceive or obtain an un lawful
608	608	payment from the health be nefit plan;
609	609	2. Failed to substantially perform the hea lthcare service;
610	610	3. Designates the incorrect entity responsible for payment ;
611	611	4. Has already been paid for the procedures identified in the
612	612	claim;
613	613	5. Submitted the claim fraudulently or the prior aut horization
614	614	was based in whole or part on erroneous info rmation provided to the
615	615	health benefit plan by the provider, patient, or other p erson not
616	616	related to the health benefit plan ; or
617	617	6. Performs a procedure or service on a patient who was not
618	618	eligible to receive the procedure or service and the health benefi t
619	619
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670	670	plan did not know, and with the exercise of reasona ble care could
671	671	not have known, of his or her eligibility status.
672	672	SECTION 4. This act shall become effective November 1, 2023.
673	673
674	674	59-1-599 RD 1/17/2023 9:32:24 AM

Oklahoma 2023 Regular Session

Oklahoma Senate Bill SB441 Compare Versions