Oklahoma 2024 Regular Session

Oklahoma House Bill HB3190 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	An Act
2		-	ENROLLED HOUSE
	1	+
	2	+
	3	+	ENGR. S. A. TO ENGR. H. B. NO. 3190 Page 1 1
	4	+	2
	5	+	3
	6	+	4
	7	+	5
	8	+	6
	9	+	7
	10	+	8
	11	+	9
	12	+	10
	13	+	11
	14	+	12
	15	+	13
	16	+	14
	17	+	15
	18	+	16
	19	+	17
	20	+	18
	21	+	19
	22	+	20
	23	+	21
	24	+	22
	25	+	23
	26	+	24
	27	+
	28	+	ENGROSSED SENATE AMENDMENT
	29	+	TO
	30	+	ENGROSSED HOUSE
3	31		BILL NO. 3190 By: Newton, Boles, Manger,
4	32		Munson, Humphrey, Burns,
5	33		McDugle, McBride,
6	34		Rosecrants, Schreiber,
7	35		Caldwell (Chad), Hasenbeck,
8	36		Dollens, West (Kevin),
9	37		Talley, Deck, Moore, West
10	38		(Rick), May, Pfeiffer,
11		-	Ford, West (Tammy), Osburn,
12		-	Hefner, Provenzano,
13		-	Roberts, and Fugate of the
14		-	House
	39	+	Ford, West (Tammy), Osburn
	40	+	of the House
15	41
16	42		and
17	43
18		-	Garvin, Coleman, and Hicks
19		-	of the Senate
	44	+	Garvin of the Senate
20	45
21	46
22	47
23		-	An Act relating to health insurance; creating the
24		-	Ensuring Transparency in Prior Aut horization Act;
25		-	defining terms; requiring disclosure and review of
26		-	prior authorization; requiring certain person nel make
27		-	adverse determinations ; prescribing requirements
28		-	related to certain appeals ; requiring consultation
29		-	prior to adverse determination; requiring certain
30		-	criteria for reviewing physicians; imposing
31		-	requirements on health benefit plans; requiring Prior
32		-	Authorization Application Programming Interface;
33		-	prescribing certain requirements related to
34		-	communications related to prior authorization s;
35		-	providing for effect of submission of information
36		-	related to health care services; providing exceptions
37		-	for prior review authorization s; prescribing
38		-	procedures related to emergency admissions;
39		-	prohibiting certain actions by health benefit plans;
40		-	imposing requirements on health benefit plans;
41		-	providing exceptions; prescribing requirements
42		-	related to prior authorizations with respect to
43		-	chronic conditions; prescribing requirements related
44		-	to inpatient acute care; prescribing requirements
45		-	related to utilization review entities; establishing
46		-	certain obligations for utilization re view entity in ENR. H. B. NO. 3190 Page 2
47		-	certain circumstances; prohibiting certain
48		-	retrospective denial; providing for length o f prior
49		-	authorization in certain circumstances; providing
50		-	continuity of care; providing for severability;
51		-	providing for noncodifi cation; providing for
52		-	codification; and providing an effective date.
	48	+	[ health insurance - Ensuring Transparency in Prior
	49	+	Authorization Act – definitions - disclosure and
	50	+	review of prior authorization - adverse
	51	+	determinations - consultation - reviewing
	52	+	physicians - obligations - utilization review
	53	+	entity - retrospective denial - length of prior
	54	+	authorization - continuity of care – severability –
	55	+	noncodification – codification - effective date ]
	56	+
	57	+
	58	+
	59	+
	60	+	AUTHOR: Add the following House Coauthor: Hefner
	61	+
	62	+	AUTHORS: Add the following Senate Coauthors: Coleman and Hicks
	63	+
	64	+	AMENDMENT NO. 1. Page 1, restore the title
	65	+
	66	+
	67	+
	68	+	ENGR. S. A. TO ENGR. H. B. NO. 3190 Page 2 1
	69	+	2
	70	+	3
	71	+	4
	72	+	5
	73	+	6
	74	+	7
	75	+	8
	76	+	9
	77	+	10
	78	+	11
	79	+	12
	80	+	13
	81	+	14
	82	+	15
	83	+	16
	84	+	17
	85	+	18
	86	+	19
	87	+	20
	88	+	21
	89	+	22
	90	+	23
	91	+	24
	92	+
	93	+	Passed the Senate the 2 5th day of April, 2024.
	94	+
	95	+
	96	+
	97	+	Presiding Officer of the Senate
	98	+
	99	+
	100	+	Passed the House of Representatives the ____ day of __________,
	101	+	2024.
	102	+
	103	+
	104	+
	105	+	Presiding Officer of the House
	106	+	of Representatives
	107	+
	108	+	ENGR. H. B. NO. 3190 Page 1 1
	109	+	2
	110	+	3
	111	+	4
	112	+	5
	113	+	6
	114	+	7
	115	+	8
	116	+	9
	117	+	10
	118	+	11
	119	+	12
	120	+	13
	121	+	14
	122	+	15
	123	+	16
	124	+	17
	125	+	18
	126	+	19
	127	+	20
	128	+	21
	129	+	22
	130	+	23
	131	+	24
	132	+
	133	+	ENGROSSED HOUSE
	134	+	BILL NO. 3190 By: Newton, Boles, Manger,
	135	+	Munson, Humphrey, Burns,
	136	+	McDugle, McBride,
	137	+	Rosecrants, Schreiber,
	138	+	Caldwell (Chad), Hasenbeck,
	139	+	Dollens, West (Kevin),
	140	+	Talley, Deck, Moore, West
	141	+	(Rick), May, Pfeiffer,
	142	+	Ford, West (Tammy), Osburn
	143	+	of the House
	144	+
	145	+	and
	146	+
	147	+	Garvin of the Senate
53	148
54	149
55	150
56	151
57	152
58		-	SUBJECT: Health insurance
	153	+	[ health insurance - Ensuring Transparency in Prior
	154	+	Authorization Act – definitions - disclosure and
	155	+	review of prior auth orization - adverse
	156	+	determinations - consultation - reviewing
	157	+	physicians - obligations - utilization review
	158	+	entity - retrospective denial - length of prior
	159	+	authorization - continuity of care – severability –
	160	+	noncodification – codification - effective date ]
	161	+
	162	+
	163	+
59	164
60	165		BE IT ENACTED BY THE PE OPLE OF THE STATE OF OKLAHOMA:
61		-
62	166		SECTION 1. NEW LAW A new section of law not to be
63	167		codified in the Oklahoma Statutes reads as follows :
64	168
	169	+	ENGR. H. B. NO. 3190 Page 2 1
	170	+	2
	171	+	3
	172	+	4
	173	+	5
	174	+	6
	175	+	7
	176	+	8
	177	+	9
	178	+	10
	179	+	11
	180	+	12
	181	+	13
	182	+	14
	183	+	15
	184	+	16
	185	+	17
	186	+	18
	187	+	19
	188	+	20
	189	+	21
	190	+	22
	191	+	23
	192	+	24
	193	+
65	194		This act shall be known and may be cited as the "Ensuring
66	195		Transparency in Prior Authorization Act".
67		-
68	196		SECTION 2. NEW LAW A new section of law to be codified
69	197		in the Oklahoma Statutes as Section 6570.1 of Title 36, unless there
70	198		is created a duplication in numbering, reads as follows :
71		-
72	199		As used in this act:
73		-
74		-	1. "Adverse determination" means a determination by a health
	200	+	1. "Adverse determination" means a determinization by a health
75	201		carrier or its designee utilization review entity that an admission,
76	202		availability of care, continued stay, or other health care service
77	203		that is a covered benefit has been reviewed and , based upon the
78	204		information provided, does not meet the health carrier's
79	205		requirements for medical necessity, appropriateness, health care
80	206		setting, level of ca re, or effectiveness, and the requested service
81	207		or payment for the service is therefore denied, reduced, or
82	208		terminated as defined by Section 6475.3 of Title 36 of the Oklahoma
83	209		Statutes;
84		-
85	210		2. "Chronic condition" means a condition that lasts one (1)
86	211		year or more and requires ongoing medi cal attention or limits
87	212		activities of daily li ving or both;
88		-
89	213		3. "Clinical criteria" means the written policies, written
90	214		screening procedures, determination rules, dete rmination abstracts,
91		-	clinical protocols, practice guidelines, medical protocols , and any ~~ENR. H. B. NO. 3190 Page 3~~
	215	+	clinical protocols, practice guidelines, medical protocols , and any
92	216		other criteria or rationale used by the utilization review entity to
93	217		determine the necessity and appropriateness of health care services;
	218	+
	219	+	ENGR. H. B. NO. 3190 Page 3 1
	220	+	2
	221	+	3
	222	+	4
	223	+	5
	224	+	6
	225	+	7
	226	+	8
	227	+	9
	228	+	10
	229	+	11
	230	+	12
	231	+	13
	232	+	14
	233	+	15
	234	+	16
	235	+	17
	236	+	18
	237	+	19
	238	+	20
	239	+	21
	240	+	22
	241	+	23
	242	+	24
94	243
95	244		4. "Emergency health care se rvices", with respect to an
96	245		emergency medical condition as defined in 42 U.S.C.A. , Section
97	246		300gg-111, means:
98		-
99	247		a. a medical screening examination , as required under
100	248		Section 1867 of the Social Secur ity Act, 42 U.S.C.,
101	249		Section 1395dd, or as would be require d under such
102	250		section if such section applied to an independent ,
103	251		freestanding emergency department , that is within the
104		-	capability of the emergency department of a hospital
	252	+	capability of the emergency department , of a hospital
105	253		or of an independent, freestanding emergency
106	254		department, as applicable, including ancil lary
107	255		services routinely available to the emergency
108	256		department to evaluate such emergency medic al
109	257		condition, and
110		-
111	258		b. within the capabilities of the staff and faciliti es
112	259		available at the hospital or the independent,
113	260		freestanding emergency department, as appli cable, such
114	261		further medical examination and treatment as are
115	262		required under Section 1395dd of the Social Security
116	263		Act, or as would be required under such section if
117	264		such section applied to an independent, freestanding
118	265		emergency department, to stabilize the patient,
119	266		regardless of the department of the hospital in which
	267	+
	268	+	ENGR. H. B. NO. 3190 Page 4 1
	269	+	2
	270	+	3
	271	+	4
	272	+	5
	273	+	6
	274	+	7
	275	+	8
	276	+	9
	277	+	10
	278	+	11
	279	+	12
	280	+	13
	281	+	14
	282	+	15
	283	+	16
	284	+	17
	285	+	18
	286	+	19
	287	+	20
	288	+	21
	289	+	22
	290	+	23
	291	+	24
	292	+
120	293		such further examination or tr eatment is furnished , as
121	294		defined by 42 U.S.C.A., Section 300gg-111;
122		-
123	295		5. "Emergency Medical Treatment and Active Labor Act " or
124	296		"EMTALA" means Section 1867 of the S ocial Security Act and
125	297		associated regulations ;
126		-
127	298		6. "Enrollee" means an individual who is enrolled in a health
128	299		care plan, including covered dependents, as defined by Section
129	300		6592.1 of Title 36 of the Oklahoma Statutes;
130		-
131	301		7. "Health care provider" means any person or other entity who
132	302		is licensed pursuant to the provisions of Title 59 or Title 63 of
133	303		the Oklahoma Statutes , or pursuant to the definition in Section 1-
134	304		1708.1C of Title 63 of the Oklahoma Statutes;
135		-	ENR. H. B. NO. 3190 Page 4
136	305		8. "Health care services " means any services provided by a
137	306		health care provider, or by an individual working for or under the
138	307		supervision of a health care provider, that relate to the diagnosis ,
139	308		assessment, prevention , treatment, or care of any human illness,
140		-	disease, injury, or condition, as defined by paragraph 2 of Section
141		-	1-1708.1C of Title 63 of the Oklahoma Statutes .
142		-
	309	+	disease, injury, or condition, as defined by Section 1-1708.1C.2 of
	310	+	Title 63 of the Oklahoma Statutes .
143	311		The term also includes the provision of mental health and su bstance
144	312		use disorder services , as defined by Section 6060.10 of Title 36 of
145	313		the Oklahoma Statutes, and the provision of durable medical
146	314		equipment. The term does not include the provision, administration,
147	315		or prescription of pharmaceutical products or services;
	316	+	9. "Licensed mental health professional " means:
148	317
149		-	9. "Licensed mental health professional " means:
	318	+	ENGR. H. B. NO. 3190 Page 5 1
	319	+	2
	320	+	3
	321	+	4
	322	+	5
	323	+	6
	324	+	7
	325	+	8
	326	+	9
	327	+	10
	328	+	11
	329	+	12
	330	+	13
	331	+	14
	332	+	15
	333	+	16
	334	+	17
	335	+	18
	336	+	19
	337	+	20
	338	+	21
	339	+	22
	340	+	23
	341	+	24
150	342
151	343		a. a psychiatrist who is a diplomate of the American
152	344		Board of Psychiatry and Neurology,
153		-
154	345		b. a psychiatrist who is a diplomate of the American
155	346		Osteopathic Board of N eurology and Psychiatry,
156		-
157	347		c. a physician licensed pursuant to the Oklahoma
158	348		Allopathic Medical and Surgical Lice nsure and
159	349		Supervision Act or the Oklahoma Osteopathi c Medicine
160	350		Act,
161		-
162	351		d. a clinical psychologist who is duly licensed to
163	352		practice by the State Boa rd of Examiners of
164	353		Psychologists,
165		-
166	354		e. a professional counselor licensed pursuant to the
167	355		Licensed Professional C ounselors Act,
168		-
169	356		f. a person licensed as a clinical soci al worker pursuant
170	357		to the provisions of the Social Worker's Licensing
171	358		Act,
172		-
173	359		g. a licensed marital and family th erapist as defined i n
174	360		the Marital and Family Therapist Licensure Act,
175		-
176	361		h. a licensed behavioral practitioner as defined in the
177	362		Licensed Behavioral Practitioner Act,
178		-
179	363		i. an advanced practice nurse as defined in the Oklahoma
180		-	Nursing Practice Act, ENR. H. B. NO. 3190 Page 5
181		-
	364	+	Nursing Practice Act,
182	365		j. a physician assistant who is licensed in good standing
183	366		in this state, or
	367	+
	368	+	ENGR. H. B. NO. 3190 Page 6 1
	369	+	2
	370	+	3
	371	+	4
	372	+	5
	373	+	6
	374	+	7
	375	+	8
	376	+	9
	377	+	10
	378	+	11
	379	+	12
	380	+	13
	381	+	14
	382	+	15
	383	+	16
	384	+	17
	385	+	18
	386	+	19
	387	+	20
	388	+	21
	389	+	22
	390	+	23
	391	+	24
184	392
185	393		k. a licensed alcohol and drug counselor/mental health
186	394		(LADC/MH) as defined in t he Licensed Alcohol and Drug
187	395		Counselors Act;
188		-
189	396		10. "Medically necessary" means services or supplies provided
190	397		by a health care provider that are:
191		-
192	398		a. appropriate for the symptoms and diagnosis or
193	399		treatment of the enrollee's condition, illness,
194	400		disease, or injury,
195		-
196	401		b. in accordance with standards of good medical practice,
197		-
198	402		c. not primarily for the convenience of the enrollee or
199	403		the enrollee's health care provider, and
200		-
201	404		d. the most appropriate supply or level of ser vice that
202	405		can safely be provided to the enrollee as defined by
203	406		Section 6592 of Title 36 of the Oklahoma Statutes;
204		-
205	407		11. "Notice" means communication delivered either
206	408		electronically or through the United States Postal Service or common
207	409		carrier;
208		-
209	410		12. "Physician" means an allopathic or osteopathic physician
210	411		licensed by the State of Oklahoma or another state to practice
211	412		medicine;
212		-
213	413		13. "Prior authorization" means the process by which
214	414		utilization review entities determine the medical necessity and
215	415		medical appropriateness of otherwise covered health care services
216	416		prior to the rendering of such health c are services. The term shall
	417	+
	418	+	ENGR. H. B. NO. 3190 Page 7 1
	419	+	2
	420	+	3
	421	+	4
	422	+	5
	423	+	6
	424	+	7
	425	+	8
	426	+	9
	427	+	10
	428	+	11
	429	+	12
	430	+	13
	431	+	14
	432	+	15
	433	+	16
	434	+	17
	435	+	18
	436	+	19
	437	+	20
	438	+	21
	439	+	22
	440	+	23
	441	+	24
	442	+
217	443		include "authorization", "pre-certification", and any other term
218	444		that would be a reliable determination by a health benefit plan.
219	445		The term shall not be construed to include or refer to s uch
220	446		processes as they may pertain to ph armaceutical services ;
221		-
222	447		14. "Urgent health care service" means a health care service
223	448		with respect to which the application of the time periods for making
224	449		an urgent care determination, which, in the opinion of a physician
225		-	with knowledge of the enrollee's medical condition: ENR. H. B. NO. 3190 Page 6
226		-
	450	+	with knowledge of the enrollee's medical condition:
227	451		a. could seriously jeopardize the life or health of the
228	452		enrollee or the ability of the enrollee to re gain
229	453		maximum function, or
230		-
231	454		b. in the opinion of a physician with knowledge of the
232	455		claimant's medical condition, would subject the
233	456		enrollee to severe pain that cannot be adequately
234	457		managed without the care or t reatment that is the
235	458		subject of the utilizatio n review; and
236		-
237	459		15. "Utilization review entity" means an individual or entity
238	460		that performs prior authorization for a health benefit plan as
239	461		defined by Section 6060.4 of Title 36 of the Oklahoma Statutes, but
240	462		shall not include any health plan offered by a contracted entity
241	463		defined in Section 4002.2 of Title 56 of the Oklahoma Statu tes that
242	464		provides coverage to members o f the state Medicaid program or other
243		-	insurance subject to the Long-Term Care Insurance Act.
	465	+	insurance subject to the Long Term Care Insurance Act .
	466	+
	467	+	ENGR. H. B. NO. 3190 Page 8 1
	468	+	2
	469	+	3
	470	+	4
	471	+	5
	472	+	6
	473	+	7
	474	+	8
	475	+	9
	476	+	10
	477	+	11
	478	+	12
	479	+	13
	480	+	14
	481	+	15
	482	+	16
	483	+	17
	484	+	18
	485	+	19
	486	+	20
	487	+	21
	488	+	22
	489	+	23
	490	+	24
244	491
245	492		SECTION 3. NEW LAW A new section of law to be co dified
246	493		in the Oklahoma Stat utes as Section 6570.2 of Title 36, unless there
247	494		is created a duplication in numbering, reads as follows:
248		-
249	495		A utilization review enti ty shall make any current prior
250	496		authorization requirements and restric tions, including written
251	497		clinical criteria, readily accessible on its website to enrollees
252	498		and health care providers. Prior authorization requirements shall
253	499		be described in detail b ut also in easily understandab le language.
254		-
255	500		If a utilization review entity intends eit her to implement a new
256	501		prior authorization requirement or restriction, or amend an existing
257	502		requirement or restriction, the utilization review entity shall
258	503		ensure that the new or amended requirement or restriction is not
259	504		implemented unless the utilization review entity 's website has been
260	505		updated to reflect the new or amended requirement or restriction.
261		-
262	506		If a utilization review entit y intends either to implement a new
263	507		prior authorization requirement or res triction, or amend an existing
264	508		requirement or restriction, the utilization review entity sha ll
265	509		provide contracted health care providers credentialed to perform the
266	510		service, or enrollees who have a chronic condition and are already
267	511		receiving the service for which the prior authorization changes will
268	512		impact, notice of the new or amended requirement or restriction no
269	513		less than sixty (60) days before the requirement or restriction is
270		-	implemented. ENR. H. B. NO. 3190 Page 7
	514	+	implemented.
	515	+
	516	+	ENGR. H. B. NO. 3190 Page 9 1
	517	+	2
	518	+	3
	519	+	4
	520	+	5
	521	+	6
	522	+	7
	523	+	8
	524	+	9
	525	+	10
	526	+	11
	527	+	12
	528	+	13
	529	+	14
	530	+	15
	531	+	16
	532	+	17
	533	+	18
	534	+	19
	535	+	20
	536	+	21
	537	+	22
	538	+	23
	539	+	24
271	540
272	541		SECTION 4. NEW LAW A new section of law to be codified
273	542		in the Oklahoma Statutes as Section 6570.3 of Title 36, unless there
274	543		is created a duplication in numbering, reads as follows:
275		-
276	544		A utilization review e ntity shall ensure that all adverse
277	545		determinations are made by a physician or licensed mental health
278	546		professional. The physician or licensed mental health professional
279	547		shall:
280		-
281	548		1. Possess a current and valid nonrestricted license in any
282	549		United States jurisdiction;
283		-
284	550		2. Have the appropriate training, knowledge, or expertise to
285	551		apply appropriate clinical guidelines to the health care service
286	552		being requested; and
287		-
288	553		3. Make the adverse determination und er the clinical direction
289	554		of one of the utilization review en tity's medical directors who is
290	555		responsible for the p rovision of reviewing health care services to
291	556		enrollees of Oklahoma. All such medical directors must be
292	557		physicians licensed in any United States jurisdiction.
293		-
294	558		SECTION 5. NEW LAW A new section of law to be codified
295	559		in the Oklahoma Statutes as Section 6570.4 of Title 36, unless there
296	560		is created a duplication in numbering, reads as follows:
297		-
298	561		A utilization review entity shall ensure that all appeals are
299	562		reviewed by a physician or licensed mental health professional . The
300	563		physician or licensed mental health professional shall:
301	564
	565	+	ENGR. H. B. NO. 3190 Page 10 1
	566	+	2
	567	+	3
	568	+	4
	569	+	5
	570	+	6
	571	+	7
	572	+	8
	573	+	9
	574	+	10
	575	+	11
	576	+	12
	577	+	13
	578	+	14
	579	+	15
	580	+	16
	581	+	17
	582	+	18
	583	+	19
	584	+	20
	585	+	21
	586	+	22
	587	+	23
	588	+	24
	589	+
302	590		1. Possess a current and va lid unrestricted license in any
303	591		United States jurisdiction;
304		-
305	592		2. Be of the same or similar special ty as a physician or
306	593		licensed mental health professional who typically manages the
307	594		medical condition or disease , which means that th e physician either
308	595		maintains board certification for the same or similar speci alty as
309	596		the medical condition in question or wh ose training and experience:
310		-
311	597		a. includes treating the condition ,
312		-
313	598		b. includes treating complications that may result from
314	599		the service or procedure, and
315		-	ENR. H. B. NO. 3190 Page 8
316	600		c. is sufficient for the physician or licensed mental
317	601		health professional to determine if the service o r
318	602		procedure is medically necessary or clinically
319	603		appropriate,
320		-
321	604		except for appeals coming from a licensed mental health
322	605		professional, which may be conducted by another licensed mental
323	606		health professional as opposed to a physician;
324		-
325	607		3. Not have been directly involved in mak ing the adverse
326	608		determination;
327		-
328	609		4. Not have any financial interest in the outcome of the
329	610		appeal; and
330		-
331	611		5. Consider all known clinical aspects of the health care
332	612		service under review, including , but not limited to, a review of
333	613		those medical records which are pertinent and relevant to the active
	614	+
	615	+	ENGR. H. B. NO. 3190 Page 11 1
	616	+	2
	617	+	3
	618	+	4
	619	+	5
	620	+	6
	621	+	7
	622	+	8
	623	+	9
	624	+	10
	625	+	11
	626	+	12
	627	+	13
	628	+	14
	629	+	15
	630	+	16
	631	+	17
	632	+	18
	633	+	19
	634	+	20
	635	+	21
	636	+	22
	637	+	23
	638	+	24
	639	+
334	640		condition provided to the utilization review entity by the
335	641		enrollee's health care provider, or a health care facility, and any
336	642		pertinent medical literature provided to the utilization review
337	643		entity by the health care provider.
338		-
339	644		SECTION 6. NEW LAW A new s ection of law to be codified
340	645		in the Oklahoma Statutes as Section 6570.5 of Title 36, unless there
341	646		is created a duplicatio n in numbering, reads as follows:
342		-
343	647		A. For plan years beginning on or after January 1, 2027, a
344	648		health benefit plan must implement and maintain a Prior
345	649		Authorization Application Programming Interf ace (API), as described
346	650		in 45 C.F.R. Part 156.
347		-
348	651		B. By July 1, 2027, health care providers must have electronic
349	652		health records or practice management systems that are compatible
350	653		with the API.
351		-
352	654		C. As of the effective date of this act, a utilization review
353	655		entity must provide health care providers with the followin g
354	656		opportunities for communication during the prior authorization
355	657		process:
356		-
357	658		1. Make staff available at least eight (8) hours a day during
358	659		normal business hours for inbound telephone calls regarding prior
359	660		authorization issues;
360		-	ENR. H. B. NO. 3190 Page 9
361	661		2. Allow staff to receive inbound communication regarding prior
362	662		authorization issues after normal business hours; and
363	663
	664	+	ENGR. H. B. NO. 3190 Page 12 1
	665	+	2
	666	+	3
	667	+	4
	668	+	5
	669	+	6
	670	+	7
	671	+	8
	672	+	9
	673	+	10
	674	+	11
	675	+	12
	676	+	13
	677	+	14
	678	+	15
	679	+	16
	680	+	17
	681	+	18
	682	+	19
	683	+	20
	684	+	21
	685	+	22
	686	+	23
	687	+	24
	688	+
364	689		3. Provide a treating provider with the opportunity to discuss
365	690		a prior authorization denial with an appropriat e reviewer.
366		-
367	691		SECTION 7. NEW LAW A new section of law to be codified
368	692		in the Oklahoma Statutes as Section 6570.6 of Title 36, unless there
369	693		is created a duplication in number ing, reads as follows:
370		-
371	694		A. If a utilization review entity requires prior authorization
372	695		of a health care service, the utilization review entity must make a
373	696		prior authorization or adverse determinati on and notify the enrollee
374	697		and the enrollee's h ealth care provider of the prior authorization
375	698		or adverse determination in accordance with the time frames set
376	699		forth below:
377		-
378	700		1. For purposes of approving prio r authorization for urgent
379	701		health care services, within seventy-two (72) hours of obtaining all
380	702		necessary information to make the pr ior authorization or adv erse
381	703		determination; or
382		-
383	704		2. For purposes of approving prior authorization for non-urgent
384	705		health care services, within seven (7) days of obtaining all
385	706		necessary information to make the prior authorization or adverse
386	707		determination.
387		-
388	708		For purposes of this section, "necessary information" includes,
389	709		but is not limited to, the results of any face-to-face clinical
390	710		evaluation or second opinion that may be required.
391		-
392	711		B. For those health care providers that submit all necessary
393	712		information through the utilization review entit y's authorized prior
	713	+
	714	+	ENGR. H. B. NO. 3190 Page 13 1
	715	+	2
	716	+	3
	717	+	4
	718	+	5
	719	+	6
	720	+	7
	721	+	8
	722	+	9
	723	+	10
	724	+	11
	725	+	12
	726	+	13
	727	+	14
	728	+	15
	729	+	16
	730	+	17
	731	+	18
	732	+	19
	733	+	20
	734	+	21
	735	+	22
	736	+	23
	737	+	24
	738	+
394	739		authorization system, health care services are deemed authorized if
395	740		a utilization review entity fails to comply with the deadline s set
396	741		forth in this section.
397		-
398	742		C. In the notification to the health care provide r that a prior
399	743		authorization has bee n approved, the utilization review entity shall
400	744		include in such notification the duration of the prior authorization
401	745		or the date by which the prior authorization will expire.
402		-
403	746		SECTION 8. NEW LAW A new section of law to b e codified
404	747		in the Oklahoma Statutes as Section 6570.7 of Title 36, unless there
405		-	is created a duplicat ion in numbering, reads as follows: ENR. H. B. NO. 3190 Page 10
406		-
	748	+	is created a duplicat ion in numbering, reads as follows:
407	749		A. A utilization review entity shall not require prior
408	750		authorization for pre -hospital transportation, for the provision of
409	751		emergency health care services , or for transfers between facilitie s
410	752		as required by the Emergency Medical Treatment and Active Labor Act.
411		-
412	753		B. A utilization review entity s hall allow an enrollee and the
413	754		enrollee's health care provider a minimum of twenty-four (24) hours
414	755		following an emergency admission or provision of emergency health
415	756		care services for the enrollee or health care provider to notify the
416	757		utilization review ent ity of the admission or provision of health
417	758		care services. If the admission or health care service occurs on a
418	759		holiday or weekend, a utilization review entity cannot require
419	760		notification until the next business day after the admission or
420	761		provision of the health care services.
421	762
	763	+	ENGR. H. B. NO. 3190 Page 14 1
	764	+	2
	765	+	3
	766	+	4
	767	+	5
	768	+	6
	769	+	7
	770	+	8
	771	+	9
	772	+	10
	773	+	11
	774	+	12
	775	+	13
	776	+	14
	777	+	15
	778	+	16
	779	+	17
	780	+	18
	781	+	19
	782	+	20
	783	+	21
	784	+	22
	785	+	23
	786	+	24
	787	+
422	788		C. A utilization review entity shall cover emergency health
423	789		care services in accordance with the requirement s of Section 6907 of
424	790		Title 36 of the Oklahoma Statut es.
425		-
426	791		SECTION 9. NEW LAW A new section of law to be codified
427	792		in the Oklahoma Statutes as Section 6570.8 of Title 36, unless there
428	793		is created a duplication in numbering, reads as follows:
429		-
430	794		A. A health benefit plan may not revoke, limit , condition, or
431	795		restrict a prior authorization if care is provided with in forty-five
432	796		(45) business days from the date the health care provider re ceived
433	797		the prior authorization unless the enrollee was no longer eligi ble
434	798		for care on the day care was provi ded.
435		-
436	799		B. A health benefit plan must pay a contracted health care
437	800		provider at the contracted payment rate for a health care service
438	801		provided by the health care provider per a prior authorization,
439	802		unless:
440		-
441	803		1. The health care provi der knowingly and materially
442	804		misrepresented the health care service in the prior authorization
443	805		request with the specific intent to deceive and obtain an unlawful
444	806		payment from a utilization review entity;
445		-
446	807		2. The health care service was no longer a covered benefit on
447	808		the day it was provided;
	809	+	3. The health care provider was no longer contracted with t he
	810	+	patient's health benefit plan on the date the care was provided;
448	811
449		-	3. The health care provider was no longer contracted with t he
450		-	patient's health benefit plan on the date the care was provided; ENR. H. B. NO. 3190 Page 11
	812	+	ENGR. H. B. NO. 3190 Page 15 1
	813	+	2
	814	+	3
	815	+	4
	816	+	5
	817	+	6
	818	+	7
	819	+	8
	820	+	9
	821	+	10
	822	+	11
	823	+	12
	824	+	13
	825	+	14
	826	+	15
	827	+	16
	828	+	17
	829	+	18
	830	+	19
	831	+	20
	832	+	21
	833	+	22
	834	+	23
	835	+	24
451	836
452	837		4. The health care provider failed to meet the utilization
453	838		review entity's timely filing requirements; or
454		-
455	839		5. The patient was no longer eligible for health care covera ge
456	840		on the day the care was p rovided.
457		-
458	841		SECTION 10. NEW LAW A new section of law to be codified
459	842		in the Oklahoma Statutes as Section 6570.9 of Title 36, unless there
460	843		is created a duplication i n numbering, reads as follows:
461		-
462	844		A. If a prior authorization is required f or a health care
463	845		service, other than for inpatient care, for the treatment of a
464	846		chronic condition of an enrollee, then the prior authorization shall
465	847		remain valid for at least six (6) months from the date the health
466	848		care provider receives the prior authoriz ation approval, unless
467	849		clinical criteria changes and notice of the change in clinical
468	850		criteria is provided as stipulated in this act.
469		-
470	851		B. If a prior authorization is required for inpa tient acute
471	852		care for the treatment of a chronic condition of an enrollee, then
472	853		the prior authorization shall remain valid for at least fourteen
473	854		(14) calendar days from the date the health care provider receives
474	855		the prior authorization approval.
475		-
476	856		1. If an enrollee requires inpatient care beyond the length of
477	857		stay that was previously approved by the utilization review entity,
478	858		then the utilization review entity shall eval uate any prior
479	859		authorization requests for the continuation of inpatient care
480	860		according to the provisions of this act. A utilization review
	861	+
	862	+	ENGR. H. B. NO. 3190 Page 16 1
	863	+	2
	864	+	3
	865	+	4
	866	+	5
	867	+	6
	868	+	7
	869	+	8
	870	+	9
	871	+	10
	872	+	11
	873	+	12
	874	+	13
	875	+	14
	876	+	15
	877	+	16
	878	+	17
	879	+	18
	880	+	19
	881	+	20
	882	+	21
	883	+	22
	884	+	23
	885	+	24
	886	+
481	887		entity shall not use a ny stricter criteria to determine medical
482	888		necessity and appropriateness of the continuation of inpatient care
483	889		as the utilization review entity used to e valuate the initial
484	890		request for authorization of inpatient care. A utilization review
485	891		entity shall review any relevant and pertinent literature or data
486	892		provided by the health care provider to deter mine the medical
487	893		necessity and appropriateness of the requ ested length of stay and/or
488	894		continuation of inpatient care. A prior authorization for the
489	895		continuation of inpatient care shall remain valid for a maximum of
490	896		fourteen (14) calendar days from the dat e the health care provider
491	897		receives the prior authorizatio n approval.
492		-
493	898		2. If a utilization review entity fails to respond to a health
494	899		care provider's timely prior authorization request for the
495		-	continuation of inpatient acute care before the termination of the ~~ENR. H. B. NO. 3190 Page 12~~
	900	+	continuation of inpatient acute care before the termination of the
496	901		previously approved length of stay, then the health be nefit plan
497	902		shall continue to co mpensate the health care provider at the
498	903		contracted rate for inpatient ca re provided until the utilization
499	904		review entity issues its determination on the prior authoriz ation
500	905		request.
501		-
502	906		For the purposes of this section, a timely request for
503	907		continuation of inpatient care means a request that is submitted at
504	908		least seventy-two (72) hours prior to the termination of the
505	909		previously approved prior authorization and includes all necessary
	910	+
	911	+	ENGR. H. B. NO. 3190 Page 17 1
	912	+	2
	913	+	3
	914	+	4
	915	+	5
	916	+	6
	917	+	7
	918	+	8
	919	+	9
	920	+	10
	921	+	11
	922	+	12
	923	+	13
	924	+	14
	925	+	15
	926	+	16
	927	+	17
	928	+	18
	929	+	19
	930	+	20
	931	+	21
	932	+	22
	933	+	23
	934	+	24
	935	+
506	936		information for the utilization review entity to make a
507	937		determination.
508		-
509	938		3. If a utilization review entity issues an adverse
510	939		determination to a health care provider's prior authorization
511	940		request for continuation of inpatient acute care and the health care
512	941		provider appeals the adverse determination accor ding to the
513	942		provisions of this act, then the health benefit plan shall continue
514	943		to compensate the health care provider at the contracted rate for
515	944		inpatient care provided until the appeal has been fi nalized.
516		-
517	945		C. This section does not require a health benef it plan to cover
518	946		care, treatment, or services for a health condition that the terms
519	947		of coverage otherwis e completely exclude from the policy's covered
520	948		benefits without regard for whether the care, t reatment, or services
521	949		are medically necessary.
522		-
523	950		SECTION 11. NEW LAW A new section of law to be codified
524	951		in the Oklahoma Statutes as Section 6570.10 of Title 36, unless
525	952		there is created a duplication in numbering, reads as follows:
526		-
527	953		A. On receipt of information documenting a prior auth orization
528	954		from the enrollee or from the enrollee's health care provider, a
529	955		utilization review entity shall honor a prior authorization granted
530	956		to an enrollee from a previous utilization review entity for at
531	957		least the initial sixty (60) days of an enrollee's coverage under a
532	958		new health plan.
533	959
	960	+	ENGR. H. B. NO. 3190 Page 18 1
	961	+	2
	962	+	3
	963	+	4
	964	+	5
	965	+	6
	966	+	7
	967	+	8
	968	+	9
	969	+	10
	970	+	11
	971	+	12
	972	+	13
	973	+	14
	974	+	15
	975	+	16
	976	+	17
	977	+	18
	978	+	19
	979	+	20
	980	+	21
	981	+	22
	982	+	23
	983	+	24
	984	+
534	985		B. During the time period described in subsection A of this
535	986		section, a utilization review entity may perform its own review to
536	987		grant a prior authorization or make an adverse determination.
537		-
538	988		C. A utilization review entity s hall continue to honor a prior
539	989		authorization it has granted to an enrollee when the enrollee
540		-	changes products under the same health insurance company for the ~~ENR. H. B. NO. 3190 Page 13~~
	990	+	changes products under the same health insurance company for the
541	991		initial sixty (60) days of an enrollee's co verage under the new
542	992		product unless the service i s no longer a covered service under the
543	993		new product.
544		-
545	994		SECTION 12. NEW LAW A new section of law to be codified
546	995		in the Oklahoma Statutes as Section 6570.11 of Title 36, unless
547	996		there is created a duplication in numbering, reads as f ollows:
548		-
549	997		If any provision of this act or the application thereof to any
550	998		person or circumstance is held invalid, such in validity shall not
551	999		affect other provisions or applications of the act which can be
552	1000		given effect without the invalid provision or applicati on, and to
553	1001		this end, the provisions of this act are declared to be severable.
	1002	+	SECTION 13. This act shall become effective January 1, 2025.
554	1003
555		-	SECTION 13. This act shall become effective January 1, 2025.
556		-	ENR. H. B. NO. 3190 Page 14
557		-	Passed the House of Representatives the 9th day of May, 2024.
	1004	+	ENGR. H. B. NO. 3190 Page 19 1
	1005	+	2
	1006	+	3
	1007	+	4
	1008	+	5
	1009	+	6
	1010	+	7
	1011	+	8
	1012	+	9
	1013	+	10
	1014	+	11
	1015	+	12
	1016	+	13
	1017	+	14
	1018	+	15
	1019	+	16
	1020	+	17
	1021	+	18
	1022	+	19
	1023	+	20
	1024	+	21
	1025	+	22
	1026	+	23
	1027	+	24
	1028	+
	1029	+	Passed the House of Representatives the 13th day of March, 2024.
558	1030
559	1031
560	1032
561	1033
562	1034		Presiding Officer of the House
563	1035		of Representatives
564	1036
565	1037
566	1038
567		-	Passed the Senate the ~~25th~~ day of ~~April~~, 2024.
	1039	+	Passed the Senate the ___ day of __________, 2024.
568	1040
569	1041
570	1042
571	1043
572	1044		Presiding Officer of the Senate
573	1045
574		-
575		-	OFFICE OF THE GOVERNOR
576		-	Received by the Office of the Governor this ____________________
577		-	day of ___________________, 20_______, at _______ o'clock _______ M.
578		-	By: _________________________________
579		-	Approved by the Governor of the State of Oklahoma this _________
580		-	day of ___________________, 20_______, at _______ o'clock _______ M.
581		-
582		-
583		-	_________________________________
584		-	Governor of the State of Oklahoma
585		-
586		-	OFFICE OF THE SECRETARY OF STATE
587		-	Received by the Office of the Secretary of State this __________
588		-	day of ___________________, 20____ ___, at _______ o'clock _______ M.
589		-	By: _________________________________
590		-