An Act
ENROLLED HOUSE
BILL NO. 3190 By: Newton, Boles, Manger,
Munson, Humphrey, Burns,
McDugle, McBride,
Rosecrants, Schreiber,
Caldwell (Chad), Hasenbeck,
Dollens, West (Kevin),
Talley, Deck, Moore, West
(Rick), May, Pfeiffer,
Ford, West (Tammy), Osburn,
Hefner, Provenzano,
Roberts, and Fugate of the
House
and
Garvin, Coleman, and Hicks
of the Senate
An Act relating to health insurance; creating the
Ensuring Transparency in Prior Aut horization Act;
defining terms; requiring disclosure and review of
prior authorization; requiring certain person nel make
adverse determinations ; prescribing requirements
related to certain appeals ; requiring consultation
prior to adverse determination; requiring certain
criteria for reviewing physicians; imposing
requirements on health benefit plans; requiring Prior
Authorization Application Programming Interface;
prescribing certain requirements related to
communications related to prior authorization s;
providing for effect of submission of information
related to health care services; providing exceptions
for prior review authorization s; prescribing
procedures related to emergency admissions;
prohibiting certain actions by health benefit plans;
imposing requirements on health benefit plans;
providing exceptions; prescribing requirements
related to prior authorizations with respect to
chronic conditions; prescribing requirements related
to inpatient acute care; prescribing requirements
related to utilization review entities; establishing
certain obligations for utilization re view entity in ENR. H. B. NO. 3190 Page 2
certain circumstances; prohibiting certain
retrospective denial; providing for length o f prior
authorization in certain circumstances; providing
continuity of care; providing for severability;
providing for noncodifi cation; providing for
codification; and providing an effective date.
SUBJECT: Health insurance
BE IT ENACTED BY THE P EOPLE 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 :
This act shall be known and may be 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 numbering, reads as follows :
As used in this act:
1. "Adverse determination" means a determination by a health
carrier or its designee utilization review entity that an admission,
availability of care, continued stay, or other health care service
that is a covered benefit has been reviewed and , based upon the
information provided, does not meet the health carrier's
requirements for medical necessity, appropriateness, health care
setting, level of ca re, or effectiveness, and the requested service
or payment for the service is therefore denied, reduced, or
terminated as defined by Section 6475.3 of Title 36 of the Oklahoma
Statutes;
2. "Chronic condition" means a condition that lasts one (1)
year or more and requires ongoing medi cal attention or limits
activities of daily li ving or both;
3. "Clinical criteria" means the written policies, written
screening procedures, determination rules, dete rmination abstracts,
clinical protocols, practice guidelines, medical protocols , and any ENR. H. B. NO. 3190 Page 3
other criteria or rationale used by the utilization review entity to
determine the necessity and appropriateness of health care services;
4. "Emergency health care se rvices", with respect to an
emergency medical condition as defined in 42 U.S.C.A. , Section
300gg-111, means:
a. a medical screening examination , as required under
Section 1867 of the So cial Security Act, 42 U.S.C.,
Section 1395dd, or as would be require d under such
section if such section applied to an independent ,
freestanding emergency depar tment, that is within the
capability of the emergency department of a hospital
or of an independent, freestanding emergency
department, as applicable, including ancil lary
services routinely available to the emergency
department to evaluate such emergency m edical
condition, and
b. within the capabilities of the staff and faciliti es
available at the hospital or the independent ,
freestanding emergency department, as appli cable, such
further medical examination and treatment as are
required under Section 1395dd of the Social Security
Act, or as would be required under such section if
such section applied to an independent, freestanding
emergency department, to stabilize the patient,
regardless of the department of the hospital in which
such further examination or treatment is furnished, as
defined by 42 U.S.C.A., Section 300gg-111;
5. "Emergency Medical Treatment and Active Labor Act " or
"EMTALA" means Section 1867 of the S ocial Security Act and
associated regulations ;
6. "Enrollee" means an individual who is enrolled in a health
care plan, including covered dependents, as defined by Section
6592.1 of Title 36 of the Oklaho ma Statutes;
7. "Health care provider" means any person or other entity who
is licensed pursuant to the provisions of Title 59 or Title 63 of
the Oklahoma Statutes, or pursuant to the definition in Section 1-
1708.1C of Title 63 of the Oklahoma Statutes;
ENR. H. B. NO. 3190 Page 4
8. "Health care services " means any services provided by a
health care provider, or by an individual working for or under the
supervision of a health care provider, that relate to the diagnosis ,
assessment, prevention , treatment, or care of any human illne ss,
disease, injury, or condition, as defined by paragraph 2 of Section
1-1708.1C of Title 63 of the Oklahoma Statutes .
The term also includes the provision of mental health and substance
use disorder services , as defined by Section 6060.10 of Title 36 of
the Oklahoma Statutes , and the provision of durable medical
equipment. The term does not include the provision, administration,
or prescription of pharmaceutical products or services;
9. "Licensed mental health professional " means:
a. a psychiatrist who is a diplomate of the American
Board of Psychiatry and Neurology,
b. a psychiatrist who is a diplomate of the American
Osteopathic Board of Neurology and Psychiatry,
c. a physician licensed pursuant to the Oklahoma
Allopathic Medical and Surgical Licensure and
Supervision Act or the Oklahoma Osteopathi c Medicine
Act,
d. a clinical psychologist who is duly licensed to
practice by the State Board of Examiners of
Psychologists,
e. a professional counselor licensed pursuant to the
Licensed Professional Counselors Act,
f. a person licensed as a clinical soci al worker pursuant
to the provisions of the Social Worker's Licensing
Act,
g. a licensed marital and family therapist as defined i n
the Marital and Family Therapist Licensure Act,
h. a licensed behavioral practitioner as defined in the
Licensed Behavioral Practitioner Act,
i. an advanced practice nurse as defined in the Oklahoma
Nursing Practice Act, ENR. H. B. NO. 3190 Page 5
j. a physician assistant who is licensed in good standing
in this state, or
k. a licensed alcohol and drug counselor/mental health
(LADC/MH) as defined in t he Licensed Alcohol and Drug
Counselors Act;
10. "Medically necessary" means services or supplies provided
by a health care provider that are:
a. appropriate for the symptoms and dia gnosis or
treatment of the enrollee's condition, illness,
disease, or injury,
b. in accordance with standards of good medical practice,
c. not primarily for the convenience of the enrollee or
the enrollee's health care provider, and
d. the most appropriate supply or level of ser vice that
can safely be provided to the enrollee as defined by
Section 6592 of Title 36 of the Oklahoma Statutes;
11. "Notice" means communication delivered either
electronically or through the United States Postal Service or common
carrier;
12. "Physician" means an allopathic or osteopathic physician
licensed by the State of Oklahoma or another state to practice
medicine;
13. "Prior authorization" means the process by which
utilization review entities determine the medica l necessity and
medical appropriateness of otherwise covered health care services
prior to the rendering of such health c are services. The term shall
include "authorization", "pre-certification", and any other term
that would be a reliable determination by a health benefit plan.
The term shall not be construed to include or refer to s uch
processes as they may pertain to ph armaceutical services ;
14. "Urgent health care service" means a health care service
with respect to which the application of the time periods for making
an urgent care determination, which, in the opinion of a physician
with knowledge of the enrollee's medical condition: ENR. H. B. NO. 3190 Page 6
a. could seriously jeopardize the life or health of the
enrollee or the ability of the enrollee to re gain
maximum function, or
b. in the opinion of a physician with knowledge of the
claimant's medical condition, would 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; and
15. "Utilization review entity" means an individual or entity
that performs prior authorization for a health benefit plan as
defined by Section 6060.4 of Title 36 of the Oklahoma Statutes, but
shall not include any health plan offered by a contracted enti ty
defined in Section 4002.2 of Title 56 of the Oklahoma Statu tes that
provides coverage to members o f the state Medicaid program or other
insurance subject to the Long-Term Care Insurance Act.
SECTION 3. NEW LAW A new section of law to be codified
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 enti ty shall make any current prior
authorization requirements and restric tions, including written
clinical criteria, readily accessible on its website to enrollees
and health care providers. Prior authorization requirements shall
be described in detail but also in easily understandable language.
If a utilization review entity intends eit her 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 or restriction is not
implemented unless the utilization review entity's website has been
updated to reflect the new or amended requirement or restriction.
If a utilization review entit y intends either to implement a new
prior authorization requirement or res triction, or amend an existing
requirement or restriction, the utilization review entity sha ll
provide contracted health care providers credentialed to perform the
service, or enrollees who have a chronic condition and are already
receiving the service for which the prior authorization changes will
impact, notice of the new or amended requirement or restriction no
less than sixty (60) days before the requirement or restriction is
implemented. ENR. H. B. NO. 3190 Page 7
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:
A utilization review e ntity shall ensure that all adverse
determinations are made by a physician or licensed mental health
professional. The physician or licensed mental health professional
shall:
1. Possess a current an d valid nonrestricted license in any
United States jurisdiction;
2. Have the appropriate training, knowledge, or expertise to
apply appropriate clinical guidelines to the health care service
being requested; and
3. Make the adverse determination under the cli nical direction
of one of the utilization review en tity's medical directors who is
responsible for the provision of reviewing health care services to
enrollees of Oklahoma. All such medical direct ors must be
physicians licensed in any United States jurisdiction.
SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as S ection 6570.4 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A utilization review entity shall ensure that all appeals are
reviewed by a physician or licensed mental health professional . The
physician or licensed mental health professional shall:
1. Possess a current and va lid unrestricted license in any
United States jurisdiction;
2. Be of the same or similar special ty as a physician or
licensed mental health professional who typically manages the
medical condition or disease, which means that th e physician either
maintains board certification for the same or similar speci alty as
the medical condition in question or wh ose training and experience:
a. includes treating the condition ,
b. includes treating complicatio ns that may result from
the service or procedure, and
ENR. H. B. NO. 3190 Page 8
c. is sufficient for the physician or licensed mental
health professional to determine if the service o r
procedure is medically necessary or clinically
appropriate,
except for appeals coming from a licensed mental health
professional, which may be conducted by another licensed mental
health professional as opposed to a physician;
3. Not have been directly involved in mak ing the adverse
determination;
4. Not have any financial interest in the outcome of the
appeal; and
5. Consider all known clinical aspects of the health care
service under review, including , but not limited to, a review of
those medical records which are pertinent and relevant to the active
condition provided to the utilization review entity by the
enrollee's health care provider, or a health care facility, and any
pertinent medical literature provided to the utilization review
entity by the health care provider.
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 duplicatio n in numbering, reads as follows:
A. For plan years beginning on or after January 1, 2027, a
health benefit plan must implement and maintain a Prior
Authorization Application Programming Interf ace (API), as described
in 45 C.F.R. Part 156.
B. By July 1, 2027, health care providers must have electronic
health records or practice management systems that are compatible
with the API.
C. As of the effective date of this act, a utilization review
entity must provide health care providers with the followin g
opportunities for communication during the prior authorization
process:
1. Make staff available at least eight (8) hours a day during
normal business hours for inbound telephone calls regarding prior
authorization issues;
ENR. H. B. NO. 3190 Page 9
2. Allow staff to receive inbound communication regarding prior
authorization issues after normal business hours; and
3. Provide a treating provider with the opportunity to discuss
a prior authorization denial with an appropriat e reviewer.
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:
A. If a utilization review entity requires prior authorization
of a health care service, the utilization review entity must make a
prior authorization or adverse determinati on and notify the enrollee
and the enrollee's health care provider of the prior authorization
or adverse determination in accordance with the time frames set
forth below:
1. For purposes of approving prio r authorization for urgent
health care services, within seventy-two (72) hours of obtaining all
necessary information to make the prior authorization or adv erse
determination; or
2. For purposes of approving prior authorization for non-urgent
health care services, within seven (7) days of obtaining all
necessary information to make the prior authorization or adverse
determination.
For purposes of this section, "necessary information" includes,
but is not limited to, the results of any face-to-face clinical
evaluation or second opinion that may be required.
B. For those health care providers that submit all necessary
information through the utilization review entit y's authorized prior
authorization system, health care services are deemed authorized if
a utilization review entity fails to comply with the deadline s set
forth in this section.
C. In the notification to the health care provider that a prior
authorization has bee n approved, the utilization review entity shall
include in such notification the duration of the prior authorization
or the date by which the prior authorization will expire.
SECTION 8. NEW LAW A new section of law to b e codified
in the Oklahoma Statutes as Section 6570.7 of Title 36, unless there
is created a duplicat ion in numbering, reads as follows: ENR. H. B. NO. 3190 Page 10
A. A utilization review entity shall not require prior
authorization for pre -hospital transportation, for the provision of
emergency health care services , or for transfers between facilitie s
as required by the Emergency Medical Treatment and Active Labor Act.
B. A utilization review entity s hall allow an enrollee and the
enrollee's health care provider a minimum of twenty-four (24) hours
following an emergency admission or provision of emergency health
care services for the enrollee or health care provider to notify the
utilization review ent ity of the admission or provision of health
care services. If the admission or health care service 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 health care services.
C. A utilization review entity shall cover emergency health
care services in accordance with t he requirements of Section 6907 of
Title 36 of the Oklahoma Statut es.
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. A health benefit plan may not revoke, limit , condition, or
restrict a prior authorization if care is provided with in forty-five
(45) business days from the date the health care provider re ceived
the prior authorization unless the enrollee was no longer eligi ble
for care on the day care was provi ded.
B. A health benefit plan must pay a contracted 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 provi der knowingly and materially
misrepresented the health care service in the prior authorization
request with the specific intent to deceiv e and obtain an unlawful
payment from a utilization review entity;
2. The health care service 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 benefit plan on the date the care was provided; ENR. H. B. NO. 3190 Page 11
4. The health care provider failed to meet the utilization
review entity's timely filing requirements; or
5. The patient was no longer eligible for health care covera ge
on the day the care was p rovided.
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 i n numbering, reads as follows:
A. If a prior authorization is required for a health care
service, other than for inpatient care, for the treatment of a
chronic condition of an enrollee, then the prior authorization shall
remain valid for at least six (6) months from the date the health
care provider receives the prior authori zation approval, unless
clinical criteria changes and notice of the change in clinical
criteria is provided as stipulated in this act.
B. If a prior authorization is required for inpa tient acute
care for the treatment of a chronic condition of an enrolle e, then
the prior authorization shall remain valid for at least fourteen
(14) calendar days from the date the health care provider receives
the prior authorization approval.
1. If an enrollee requires inpatient care beyond the length of
stay that was previously approved by the utilization review entity,
then the utilization review entity shall eval uate any prior
authorization requests for the continuation of inpatient care
according to the provisions of this act. A utilization review
entity shall not use any stricter criteria to determine medical
necessity and appropriateness of the continuation of inpatient care
as the utilization review entity used to e valuate the initial
request for authorization of inpatient care. A utilization review
entity shall review any relevant and pertinent literature or data
provided by the health care provider to deter mine the medical
necessity and appropriateness of the requ ested length of stay and/or
continuation of inpatient care. A prior authorization for the
continuation of inpatient care shall remain valid for a maximum of
fourteen (14) calendar days from the dat e the health care provider
receives the prior authorizatio n approval.
2. If a utilization review entity fails to respond to a health
care provider's timely prior authorization request for the
continuation of inpatient acute care before the termination of the ENR. H. B. NO. 3190 Page 12
previously approved length of stay, then the health be nefit plan
shall continue to co mpensate the health care provider at the
contracted rate for inpatien t care provided until the utilization
review entity issues its determination on the prior authoriz ation
request.
For the purposes of this section, a timely request for
continuation of inpatient care means a request that is submitted at
least seventy-two (72) hours prior to the termination of the
previously approved prior authorization and includes all necessary
information for the utilization review entity to make a
determination.
3. If a utilization review entity issues an adverse
determination to a he alth care provider's prior authorization
request for continuation of inpatient acute care and the health care
provider appeals the adverse determination accor ding to the
provisions of this act, then the health benefit plan shall continue
to compensate the health care provider at the contracted rate for
inpatient care provided until the appeal has been fi nalized.
C. This section does not require a health benef it plan to cover
care, treatment, or services for a health condition that the terms
of coverage otherwise completely exclude from the policy's covered
benefits without regard for whether the care, t reatment, or services
are medically necessary.
SECTION 11. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.10 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 authorization 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 review entity may perform its own review to
grant a prior authorization or make an adverse determination.
C. A utilization review entity s hall continue to honor a prior
authorization it has granted to an enrollee when the enrollee
changes products under the same health insurance company for the ENR. H. B. NO. 3190 Page 13
initial sixty (60) days of an enrollee's co verage under the new
product unless the service i s no longer a covered service under the
new product.
SECTION 12. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.11 of Title 36, unless
there is created a duplication in numbering, reads as f ollows:
If any provision of this act or the application thereof to any
person or circumstance is held inv alid, such invalidity shall not
affect other provisions or applications of the act which can be
given effect without the invalid provision or applicati on, and to
this end, the provisions of this act are declared to be severable.
SECTION 13. This act shall become effective January 1, 2025.
ENR. H. B. NO. 3190 Page 14
Passed the House of Representatives the 9th day of May, 2024.
Presiding Officer of the House
of Representatives
Passed the Senate the 25th day of April, 2024.
Presiding Officer of the Sena te
OFFICE OF THE GOVERNOR
Received by the Office of the Governor this ____________________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________
Approved by the Governor of the State of Oklahoma this _________
day of ___________________, 20_______, at _______ o'clock _______ M.
_________________________________
Governor of the State of Oklahoma
OFFICE OF THE SECRETARY OF STATE
Received by the Office of the Secretary of State this __________
day of ___________________, 20____ ___, at _______ o'clock _______ M.
By: _________________________________