HB3190 HFLR Page 1
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
HOUSE OF REPRESENTATIVES - FLOOR VERSION
STATE OF OKLAHOMA
2nd Session of the 59th Legislatu re (2024)
HOUSE BILL 3190 By: Newton of the House
and
Garvin of the Senate
AS INTRODUCED
An Act relating to health insurance; creating the
Ensuring Transparency in Prior Authorization Act;
defining terms; requiring disclosure and review of
prior authorization; requiring certain personnel make
adverse determinations ; requiring consultation prior
to adverse determination; requiring certain cri teria
for reviewing physicians; establishing certain
obligations for utilization review entity in certain
circumstances; providing an exception for prior
authorization; prohibiting certain retrospective
denial; providing for length of prior auth orization;
providing for length of prior authorization in
certain circumstances; providing continui ty of care;
providing standard for transmission of authorization ;
providing for failure to comply ; providing for
severability; providing for noncodifi cation;
providing for codification; and providing an
effective date.
BE IT ENACTED BY THE PEO PLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law not to be
codified in the Oklahoma Statutes reads as follows:
HB3190 HFLR Page 2
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
This act may be known and cited as the "Ensuring Transparency in
Prior Authorization Act."
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.1 of Title 36, unless there
is created a duplication in n umbering, reads as follows:
As used in this act:
1. "Adverse determination" means a decision by a utilization
review entity that the health care services furnished or p roposed to
be furnished to an enrollee are not medically necessary, or are
experimental or investigational; and benefit co verage is therefore
denied, reduced, or terminated. A decision to deny, redu ce, or
terminate services that are not cover ed for reasons other than their
medical necessity or experimental or investigational nature is not
an "adverse determination " for purposes of this act;
2. "Authorization" means a determination by a utilizatio n
review entity that a health care service ha s been reviewed and,
based on the information provided, satisfies the utilization rev iew
entity's requirements for medical necessity and appro priateness, and
that payment will be made for th at health care service;
3. "Chronic condition" means a diagnosis of a disease dependent
on duration, a condition lasting twelve (12) months or longer, and
its effect on the patient based on one or both of the followi ng
criteria:
HB3190 HFLR Page 3
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
a. the condition results in the need for ongoing
intervention with medical products, treatment,
services, and specia l equipment, or
b. the condition places limitations on self -care,
independent living, and social interactions ;
4. "Clinical criteria" means the written policies, wri tten
screening procedures, drug formularies or lists of covered drugs,
determination rules, determination abstracts, clinical protocols,
practice guidelines, medical pr otocols and any other criteria or
rationale used by the utilization review entity to det ermine the
necessity and appropriateness of health care services;
5. "Emergency health care services" means those health care
services that are provided in an emergenc y facility after the sudden
onset of a medical condition that manifests itself by symptoms of
sufficient severity, including severe pain, that the absence of
immediate medical attention could reasonably be expected by a
prudent layperson, who possesses an average knowledge of health and
medicine, to result in:
a. placing the patient's health in serious jeopardy,
b. serious impairment to bodily function, or
c. serious dysfunction o f any bodily organ or part ;
6. "Enrollee" means an individual eligible to receive health
care service benefits from a health insurer purs uant to a health
HB3190 HFLR Page 4
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
plan or other health insurance cove rage. The term enroll ee includes
an enrollee's legally authorized representative ;
7. "Health care services " means health care pr ocedures,
treatments, or services:
a. provided by a facility licensed in Oklahoma, or
b. provided by a doctor of medicine, a doctor of
osteopathy, or within the scope of practice for which
a health care professional is licensed in Oklahoma.
The term "health care service" also includes the provision,
administration or prescription of pharmaceutical product s or
services or durable medical equipment;
8. "Medically necessary health care services " means health care
services that a prudent physician would provide to a patien t for the
purpose of preventing, diagnosing or treating an illness, injury,
disease or its symptoms in a manner that is:
a. in accordance with generally accepted standards of
medical practice,
b. clinically appropriate in terms of type , frequency,
extent, site, and duration, and,
c. not primarily for the economic benefit of the health
plans and purchasers or for the convenience of the
patient, treating physician, or other health care
provider;
HB3190 HFLR Page 5
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
9. "Medication for opioid use disorder (MOUD) " means the use of
medications, commonly in combination with counseling and behavioral
therapies, to provide a comprehensive appro ach to the treatment of
opioid use disorder. FDA-approved medications used to treat opioid
addiction include methadone ; buprenorphine, alone or in combination
with naloxone; and extended-release injectable naltrexone. Types of
behavioral therapies includ e individual therapy, group counseling,
family behavior therapy, mot ivational incentives, and other
modalities;
10. "NCPDP SCRIPT Standard " means the National Council for
Prescription Drug Program s SCRIPT Standard Version 2017071, or the
most recent standard adopted by the United States Department of
Health and Human Services (HHS). Subsequently rele ased versions of
the NCPDP SCRIPT Standard m ay be used;
11. "Notice" means communication delivered both electronically
and through the United States Postal Service or common carrier ;
12. "Primary care provider " means a health care professional
that works in family medicine, general internal medicine , or general
pediatrics who provides definitive care to the undifferentiated
patient at the point of first conta ct, and takes continuing
responsibility for providing the patient 's comprehensive care. This
care may include chronic, prevent ive and acute care in both
inpatient and outpatient settings;
HB3190 HFLR Page 6
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
13. "Prior authorization" means the process by which
utilization review entities determine the medical necessity and/or
medical appropriateness of otherwise covered health care services
prior to the rendering o f such health care s ervices. Prior
authorization also includes any health insurer 's or utilization
review entity's requirement that an enrollee or health care provider
notify the health insurer or utilization review entity prior to
providing a health care service;
14. "Urgent health care service" means a health care service
with respect to which the application of the time periods for making
a non-expedited prior authorization, which, in the opinion of a
physician with knowledge of the enrollee 's medical condition:
a. could seriously jeopardize the life or health of the
enrollee or the abili ty of the enrollee to re gain
maximum function, or
b. could subject the enrollee to severe pain that cannot
be adequately managed without the care or treatment
that is the subject of the utilizatio n review.
For the purpose of this act, urgent health care se rvice shall
include mental and behavioral health care services.
15. "Utilization review entity" means an individual or entity
that performs prior authorization for one or more of the following :
HB3190 HFLR Page 7
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
a. an employer with employees in Oklahoma who are covere d
under a health benefit plan or health insurance
policy,
b. an insurer that writes health insurance policies,
c. a preferred provider organization, or health
maintenance organization, or
d. any other individual or entity that pro vides, offers
to provide, or administers hospital, outp atient,
medical, prescription drug, or other health benefits
to a person treated by a health care professional in
Oklahoma under a policy, plan or contract.
SECTION 3. NEW LAW A new section of law to be codif ied
in the Oklahoma Stat utes as Section 6570.2 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A utilization review entity shall make any current prior
authorization requirements and restric tions readily accessible on
its website to enrollees, h ealth care profession als, and the general
public. This includes the written clinical criteria. Requirements
shall be described in detail b ut also in easily understandable
language.
1. If a utilization review entity intends either to implement a
new prior authorization requirement or restriction, or amend an
existing requirement or restriction, the utilization review entity
shall ensure that the new or amended requirement is not implemented
HB3190 HFLR Page 8
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
unless the utilization review entity 's website has been updated to
reflect the new or amended requirement or restriction.
2. If a utilization review entity intends either to implement a
new prior authorization requirement or restriction, o r amend an
existing requirement or restriction, the utilization review entity
shall provide contracted health care providers or en rollees written
notice of the new or amended requirement or amendment no less than
sixty (60) days before the requirement or restriction is
implemented.
3. Entities using prior authorization shall make stat istics
available regarding prior authorization approvals and denials on
there website in a readily accessible format.
They should include categ ories for:
a. physician specialty,
b. medication or diagnost ic test/procedure,
c. indication offered,
d. reason for denial,
e. if appealed,
f. if approved or denied on appeal, and
g. the time between submission and response.
SECTION 4. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.3 of Title 36, unless there
is created a duplication in numbering, reads as follows:
HB3190 HFLR Page 9
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
A utilization review entity must ensure tha t all adverse
determinations are made by a physician. The physician must:
1. Possess a current an d valid nonrestricted license to
practice medicine in Oklahoma;
2. Be of the same specialty as the physician who typi cally
manages the medical condition or disease or provides the health care
service involved in the request;
3. Have experience treating p atients with the medical con dition
or disease for which the health care service is being requested ; and
4. Make the adverse determination under the cli nical direction
of one of the utilization re view entity's medical directors who is
responsible for the p rovision of health care services provided to
enrollees of Oklahoma. All such medical directors must be
physicians licensed in Oklahoma.
SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.4 of Title 36, unless there
is created a duplicatio n in numbering, reads as follows:
If a utilization review entity questions the medical necessity
of a health care service, the utilization revie w entity must notify
the enrollee's physician that medic al necessity is being questioned.
Prior to issuing an a dverse determination, the enrollee's physician
must have the opportunity to discuss the medical necessity of the
health care service on the tele phone with the physician who will be
HB3190 HFLR Page 10
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
responsible for dete rmining authorization of the he alth care service
under review.
SECTION 6. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.5 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A utilization entity must ensure that all a ppeals are reviewed
by a physician. The physician must:
1. Possess a current and valid non restricted license to
practice medicine in Oklahoma ;
2. Be currently in active practice in the same or simil ar
specialty as a physician who typically manages the m edical condition
or disease for at least five (5) consecut ive years;
3. Be knowledgeable of, and have experience providing , the
health care services under appeal;
4. Not be employed by a utilization review entity or be under
contract with the utilization review entity other tha n to
participate in one or more of the utilization review entity 's health
care provider networks or to per form reviews of appeals, or
otherwise have any financial interest in th e outcome of the appeal;
5. Not have been directly inv olved in making the adverse
determination; and
6. Consider all known clinical aspects of the health care
service under review, including b ut not limited to, a review of all
pertinent medical records p rovided to the utilization revi ew entity
HB3190 HFLR Page 11
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
by the enrollee's health care provider, any relevant records
provided to the utilization review entity by a health care facility,
and any medical literature p rovided to the utilization review entity
by the health care provider.
SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.6 of Title 36, unless there
is created a duplication in numbering, reads as follows:
If a utilization review entity require s prior authorization of a
health care service, the uti lization review entity must make a prior
authorization or adverse determination and notify the enrollee and
the enrollee's health care provider of the prior authorization or
adverse determination withi n forty-eight (48) hours of obtaining all
necessary information to make the prior authoriz ation or adverse
determination. For purposes of this section, "necessary
information" includes the results o f any face-to-face clinical
evaluation or second opinion that may be required.
SECTION 8. NEW LAW A new section of law to b e codified
in the Oklahoma Stat utes as Section 6570.7 of Title 36, unless there
is created a duplication in n umbering, reads as follows:
A. A utilization review enti ty cannot require prior
authorization for pre-hospital transportation or for the provision
of emergency health care services.
B. A utilization review entity shall allow an enrollee and the
enrollee's health care provider a minimum of twenty-four (24) hours
HB3190 HFLR Page 12
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
following an emergency admission or provision of emergency health
care services for the enrollee or health care provide r to notify the
utilization review entity of the admission o r provision of health
care services. If the admission or health care servi ce occurs on a
holiday or weekend, a utilization review entity cannot require
notification until the next business day after the admission or
provision of the heal th care services.
C. A utilization review entity shall cover emergency health
care services necessary to screen and stabili ze an enrollee. If a
health care provider certifies in writing to a utilization review
entity within seventy-two (72) hours of an en rollee's admission that
the enrollee's condition required emergency health care services,
that certification will create a presumption that the eme rgency
health care services were medically necessary and such presump tion
may be rebutted only if the utilization review entity can establish,
with clear and convincing evidence, that the em ergency health care
services were not medi cally necessary.
D. The medical necessity or appropriateness of emergency health
care services cannot be based on whether those services were
provided by participat ing or nonparticipating providers.
Restrictions on coverage of emergency health care servi ces provided
by nonparticipating providers cannot be greater than restrictions
that apply when those services are provided by participating
providers.
HB3190 HFLR Page 13
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
E. If an enrollee receives an emergency health care service
that requires immediate post-evaluation or post-stabilization
services, a utilization review entity shall make an authorization
determination within sixty (60) minutes of receiving a request; if
the authorization determination is not made within s ixty (60)
minutes, such services shall be deemed appr oved.
SECTION 9. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.8 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A utilization review entity may not require prior authorization
for the provision of MOUD.
SECTION 10. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.9 of Title 36, unless there
is created a duplication in num bering, reads as follows:
A. A utilization review enti ty may not revoke, limit,
condition, or restrict a prior authorization if care is provided
within forty-five (45) business days from the d ate the health care
provider received the prior authorization.
B. A utilization review entity must pay a health care provider
at the contracted payment rate for a health care service provided by
the health care provider per a prior authorization unless:
1. The health care provider knowingly and materially
misrepresented the health care service in the prior authorization
HB3190 HFLR Page 14
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
request with the specific intent to deceive and obtain an unlawful
payment from utilization review entity;
2. The health care s ervice was no longer a covered benefit on
the day it was provided;
3. The health care provider was no longer contracted with t he
patient's health insurance plan on the date the care was provid ed;
4. The health care provider failed to meet th e utilization
review entity's timely filing requirements;
5. The utilization review entity does not have liability for a
claim; or
6. The patient was no longer eligible for health care covera ge
on the day the care was provided.
SECTION 11. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Sect ion 6570.10 of Title 36, unless
there is created a dupl ication in numbering, reads as follows:
A prior authorization shal l be valid for one (1) year from the
date the health care provider re ceives the prior authorization and
the authorization period shall be effective regardless of any
changes in dosage for a prescription drug prescribed by the health
care provider.
SECTION 12. NEW LAW A new section of law to be codifi ed
in the Oklahoma Statutes as Section 6570.11 of Title 36, unless
there is created a duplication in numbering, reads as f ollows:
HB3190 HFLR Page 15
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
If a utilization review entity requires a prior aut horization
for a health care service for the treatment of a chronic or long -
term care condition, the prior authorization shall remain valid for
the length of the treatment a nd the utilization revie w entity may
not require the enrollee to obtain a prior aut horization again for
the health care service.
SECTION 13. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.12 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. On receipt of information documenting a prior auth orization
from the enrollee or from the enrollee's health care provider, a
utilization review entity shall honor a prior au thorization granted
to an enrollee from a previous utilization review entity for at
least the initial sixty (60) days of an enrollee's coverage under a
new health plan.
B. During the time period described in subsection A of this
section, a utilization rev iew entity may perform i ts own review to
grant a prior authorization.
C. If there is a change in coverage of, or approval criteria
for, a previously authorized he alth care service, the change in
coverage or approval criteria does not affect an enrollee wh o
received prior authori zation before the effective date of the change
for the remainder of the enrollee 's plan year.
HB3190 HFLR Page 16
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
D. A utilization review entity shall contin ue to honor a prior
authorization it has g ranted to an enrollee when the enrollee
changes products under the same heal th insurance company .
SECTION 14. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Sect ion 6570.13 of Title 36, unless
there is created a duplication in numbering, reads as follows:
No later than January 1, 2025, the payer must accept and respond
to prior authorization requests under the pharmacy benefit through a
secure electronic transmis sion using the NCPDP SCRIPT Standard ePA
transactions. Facsimile, propriety payer portals, elect ronic forms,
or any other technology not directly integrated with a physician 's
electronic health record/electronic prescribing system shall not be
considered secure electronic transmission.
SECTION 15. NEW LAW A new section of law t o be codified
in the Oklahoma Statutes as Section 6570.14 of Title 36, unless
there is created a duplication in numbering, reads as follows:
Health care services are deemed authorized if a utilization
review entity fails to comply with the requirements of th is act.
Any failure by a utilization review entity to comply with the
deadlines and other requirements specifie d in this act will result
in any health care services subject to review to be automatically
deemed authorized by the utilization review entity.
HB3190 HFLR Page 17
BOLD FACE denotes Committee Amendments. 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
SECTION 16. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.15 of Title 36, unless
there is created a duplication in numbering, reads as follows:
If any provision of this act or the application th ereof to any
person or circumstance is held invalid, such in validity shall not
affect other provisions or applications of the act which can be
given effect without the invalid provision or application, and to
this end the provisions of this act are declared to be severable.
SECTION 17. This act shall become effective November 1, 2024.
COMMITTEE REPORT BY: COMMITTEE ON INSURANCE, dated 02/21/2024 - DO
PASS, As Coauthored.