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STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
SENATE BILL 441 By: Montgomery
AS INTRODUCED
An Act relating to health insurance; defining terms;
allowing health benefit p lan to exempt certain health
care provider from cer tain preauthorization
requirement under certain circumstances; establishing
process for preauthorization exemption; requi ring
plan to publish certain criteria; requirin g plan to
provide notice to a provider under certain
circumstances; construing provision; establishing
denial process of certain exemption ; providing for
recission of certain exemption; establishin g appeal
process; authorizing provider to request an
independent review organization review appe al;
establishing appeal determination as binding;
prohibiting retroactivity; prohibiting plan from
denying or reducing certain payment to provider under
certain circumstance s; providing for codification;
and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6890 of Title 36, unless there
is created a duplication in numbering, reads as follows:
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A. For the purposes of this act:
1. “Health benefit plan” means a health benefit plan offered by
a Health Maintenance Organization (HMO) operating under the Health
Maintenance Organization Act of 2003 pursuant to Section 6901 et
seq. of Title 36 of the Oklahoma Statutes, including a contract
between a health benefit plan and a provider to pr ovide to a patient
proposed medically necessary and appr opriate health care services ,
and a health benefit plan offered by a Preferred Provider
Organization (PPO) as defined pursuant to Section 6054 of Title 36
of the Oklahoma Statutes;
2. “Health care provider ” or “provider” means a health care
provider as defined pursuant to Sect ion 6571 of Title 36 of the
Oklahoma Statutes;
3. “Health care service” means a service as defined pursuant to
Section 1219.6 of Title 36 of t he Oklahoma Statutes;
4. “Independent review organization ” means an independent
review organization as defined pursuant to Section 6475.3 of Title
36 of the Oklahoma Statutes; and
5. “Preauthorization” means a determination by a health benefit
plan, or person contracting with a health benefit plan, that a
health care service proposed to be provided to a patient is
medically necessary and appropriate.
B. A health benefit plan that uses a preauthorization process
for health care services may exempt a health care provider from
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obtaining preauthorizati on for a particular health care service. A
health benefit plan shall evaluate whether a provider qualifies for
an exemption from preauthorization requirements once every six (6)
months. The exemption shall be granted if, in the most recent six -
month evaluation period, the health benefit plan has ap proved or
would have approved not less than ninety percent (90%) of the
preauthorization requests submitted by the provider for the health
care service.
C. A health benefit plan may continue an exemption under this
subsection without evaluating whether the provider qualifies for an
exemption for a particular evaluation period. A provider is not
required to request an exemption from preauthorization to qualify
under this act.
D. 1. A health benefit plan tha t provides any preauthorization
exemption under this act shall post the criteria for such exempt ion
on a publicly available website and a monthly updated list of h ealth
care providers who fall under the exemption.
2. A health benefit plan shall provide notice to a provider
that is eligible for a prea uthorization exemption no later than five
(5) business days after the determination has been made. The notice
shall include:
a. a statement that the provider qualifies for an
exemption from preauthorizati on requirements,
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b. a list of health care services and health benefit
plans to which the exemption applies,
c. a statement of the duration of the exemption, and
d. a notification of the health benefit plan’s payment
requirements.
3. Nothing in this subsec tion shall be construed to authorize a
provider to provide a health care service outside of the scope of
the provider’s applicable license or to require a health benefi t
plan to pay for a health care service that is per formed in violation
of the laws of this state.
E. A health benefit plan may deny an ex emption from
preauthorization only if the provider does not have the exemption at
the time of the relevant evaluation period and if the health benefit
plan provides the provider with sufficient data for the relevant
preauthorization request period that dem onstrates that the provider
does not meet the criteria for the exemption.
F. If a provider is denied a preauthorizati on exemption or has
the exemption rescinded pursuan t to Section 2 of this act, the
provider is eligible for consideration of an exemption for the same
health care service immediately after the next evaluation period
concludes.
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6891 of Title 36, unless there
is created a duplication in numbering, reads as foll ows:
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A. A health benefit plan that complies with all other
provisions of this act may rescind a provider’s exemption from
preauthorization requirements only during January or June of each
year.
B. 1. A health benefit plan shall mak e the determination to
rescind an exemption by using a retrospective review process for the
most recent evaluation period. The review shall use a sample chosen
at random of not fewer than five (5) and no more than twenty (20)
claims submitted by the provider. If findings conclude that less
than ninety percent (90%) of the sampled claim s for the particular
health service met the criteria used to previously grant the
exemption, the recission process may commence.
2. For a determination to rescind a provider’s exemption, the
determination shall be made by an individual licensed to practice
medicine in this state w ho has the same or a similar specialty as
the provider under review.
3. A health benefit plan may only conduct a retrospective
review of a healthcare service subject to an exemption if:
a. the health benefit plan has a reasonable cause to
suspect a basis of denial exists under sub section A of
this section, or
b. a review is needed to determine if the provider
administering the exemption still qu alifies for an
exemption under this act; provided , however, this
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subparagraph shall not be construed to modify or
otherwise affect any other requirements placed upo n a
health benefit plan except those outlined in
subsection A of Section 3 of this act.
C. 1. A provider’s exemption from preauthorization
requirements under this section shall remain in effect until thi rty
(30) days after the health benefit plan not ifies the provider of the
determination to rescind the exemption if the provider does not
appeal the determination. The provider shall be notified not less
than twenty-five (25) days before the proposed recis sion is to take
effect. Notice shall include all r elevant data and information used
to make the determination including, but not limited t o, the sample
information from the relevant evaluation p eriod and shall include a
plain language explanation of the p rocedures for the provider to
appeal the determinat ion.
2. If the provider appeals the determination to rescind the
preauthorization exemp tion, the exemption shall remain in effect
until the fifth day after the date that an independent rev iew
organization affirms the determination to rescind the exemption .
D. A provider has the right to a review of a determination
regarding the recission of a preauthorization exemption which shall
be conducted by an independent review organiza tion. A health
benefit plan may not require any other internal appeal process
before a provider can request a review of the determination. In
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requesting a review, the provider may request that the independent
review organization consider a different random sample under the
same provisions of subsection B of this section.
E. 1. A health benefit plan is bound by an appeal or
independent review determination that does no t affirm the
determination made by the plan to rescind a preauthorization
exemption.
2. If a determination regardin g a preauthorization exemption
made by a health benefit plan is overturned by an independent review
organization pursuant to a review, the health benefit plan shall not
attempt to rescind the ex emption before the end of the next
evaluation period.
3. A health benefit plan may not retroactively deny a hea lth
care service because of a recission of an exemption under any
circumstance.
F. An independent review organization shall complete the revie w
of a determination regarding an exemption recission no later than
the thirtieth day after the date that a provider files the request
for a review under this section.
G. If a review of a determinatio n by a health benefit plan is
conducted pursuant to this section, the health benefit plan shall
pay a fee pursuant to Section 19 of Title 76 of the Oklahoma
Statutes to obtain access to patient medical records . The health
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benefit plan shall pay for the appeal or independent review of a n
adverse determination regarding the preauthorization exemption.
SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statut es as Section 6892 of Title 36, unless there
is created a duplication in numbering, reads as f ollows:
A health benefit plan shall not deny or reduce payment to a
health care provider for a health care service for which the
provider has been exempted from preauthorizatio n requirements under
Section 1 of this act unless the provider:
1. Knowingly or materially misrepresented the health care
service in a request for payment submitted to the health benefit
plan with the specific in tent to deceive or obtain an un lawful
payment from the health be nefit plan;
2. Failed to substantially perform the hea lthcare service;
3. Designates the incorrect entity responsible for payment ;
4. Has already been paid for the procedures identified in the
claim;
5. Submitted the claim fraudulently or the prior aut horization
was based in whole or part on erroneous info rmation provided to the
health benefit plan by the provider, patient, or other p erson not
related to the health benefit plan ; or
6. Performs a procedure or service on a patient who was not
eligible to receive the procedure or service and the health benefi t
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plan did not know, and with the exercise of reasona ble care could
not have known, of his or her eligibility status.
SECTION 4. This act shall become effective November 1, 2023.
59-1-599 RD 1/17/2023 9:32:24 AM