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HOUSE OF REPRESENTATIVES - FLOOR VERSION
STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024)
HOUSE BILL 3862 By: Ford
AS INTRODUCED
An Act relating to health insurance; defining terms;
providing for disclosure and review of prior
authorization requirements; providing who shall make
adverse determinations ; providing for personnel
qualifications; requiring consultations prior to
adverse determinations; providing requirements for
certain physicians; provi ding for retrospective
denial; providing for exemptions; providing for
failure to comply; providing for codification; and
providing an effective date.
BE IT ENACTED BY THE PEOPLE OF T HE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new sect ion of law to be codified
in the Oklahoma Statutes as Se ction 6570.1 of Title 36, unless there
is created a duplication in numbering, reads as follows:
As used in this section:
1. "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 of such health care services. Prior authorization
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also includes any he alth 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; and
2. "Utilization review entity " means an individual or entity
that performs prior authorization for an:
a. insurer that writes health insurance policies , and
b. a preferred provider organization, health maintenance
organization, or exclusive provider organization.
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statut es as Section 6570.2 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. A utilization review entity shall make any current prior
authorization requirements and restrictions readily accessible on
its website to enrollees, health care professionals, and the general
public. This includes the written clinical criteria. Requirements
shall be described in detail but also in easily understandable
language.
B. 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 re view entity
shall ensure that the new or amended requirement is not implemented
unless the utilization review entity 's website has been updated t o
reflect the new or amended requirement or restriction .
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C. If a utilization review entity intends either to impl ement a
new prior authorization requirement or restriction or amend an
existing requirement or restriction, the utilization review entity
shall provide health care providers of enrollees written not ice of
the new or amended requirement or amendment no les s than sixty (60)
days before the requirement or restriction is implemented.
SECTION 3. NEW LAW A new section of law t o 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. A utilization review entity must ensure that all adverse
determinations are made by a physician.
1. The physician must:
a. possess a current and valid non -restricted license to
practice medicine in the state of Oklahoma ,
b. be of the same specialty as the physician who
typically manages the medical condition or disease or
provides the health care service involve d in the
request,
c. have experience treating patients with the medical
condition or disease for which the health care service
is being requested, and
d. make the adverse determination under the clinical
direction of one of the utilization review entity 's
medical directors who is responsible for the provision
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of health care services provided to enrollees of
Oklahoma.
SECTION 4. 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 duplication in numbering, reads as follow s:
If a utilization review entity is questioning the medical
necessity of a health care service, the utilization revie w entity
must notify the enrollee 's physician that medical necessity is bei ng
questioned. Prior to issuing an adverse determination, the
enrollee's physician must have the opportunity to discuss the
medical necessity of the health care service on the telep hone with
the physician who will be responsible for determining authorizati on
of the health care service under review.
SECTION 5. 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. A utilization review entity must ensure that all appeals are
reviewed by a physician.
1. The physician must:
a. possess a current and valid non -restricted license to
practice medicine in Oklahoma,
b. be currently in active practice in the same or similar
specialty as a physician who typically manages the
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medical condition or disease for at least five (5)
consecutive years,
c. be knowledgeable of, and have experience providing,
the health care services under appeal ,
d. not be employed by a utilization revie w entity or be
under contract with the utilization review entity
other than to participate in one or more of the
utilization review entity 's health care provider
networks or to perform reviews of appeals, or
otherwise have any financial interest in the out come
of the appeal,
e. not have been directly involved in making the adverse
determination, and
f. consider all known clinical aspects of the health
care, service under review, including , but not limited
to, a review of all pertinent medical records provi ded
to the utilization review entity 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 provided to the
utilization review entity by the health care p rovider.
SECTION 6. 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:
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A. A utilization review entity m ay not revoke, limit, condition
or restrict a prior authorization if care i s provided within forty-
five (45) business days from the date the health care provider
received the prior authorization.
B. In the case of preventive care that has prior authorization
approval, if it has been determined medically necessary by the
medical provider that additional preventive care is needed, it shall
be covered under the initial pre -authorization. For any
subsequently provided prevent ive care covered by the initial pre -
authorization, it must be in connection to care furnished by the
medical provider. Any care provided to an enrollee that is not in
connection to pre-authorized preventive care shall need to receive
pre-authorization approval.
C. Nothing in this section s hall be construed to require pre-
authorization approval of care that is already exempted from a pre -
authorization approval.
SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.7 of Title 36, unless there
is created a duplication in numbering, reads as fol lows:
A. A utilization review entity may not require a health care
provider to complete a prior authorization for a health care service
in order for the enrollee to whom the service is be ing provided to
receive coverage if in the most recent 12 -month period, the
utilization review entity has approved or would have approved not
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less than eighty percent (80%) of the prior authorization requests
submitted by the health care provider for that health care service.
B. A utilization review entity may evaluate wh ether a health
care provider continues to qualify for exemptions as described in
subsection A not more than once every twelve (12) months. Nothing
in this section requires a utilization re view entity to evaluate an
existing exemption or prevents a utilizat ion review entity from
establishing a longer exemption period.
C. A health care provider is not required to request an
exemption in order to qualify for an exemption.
D. A health care provider who does not receive an exemption may
request from the utili zation review entity at any time, but not more
than once per year per service, evidence to support the utilization
review entity's decision. A health care provider may appeal a
utilization review entity's decision to deny an exemption.
E. A utilization review entity may only revoke an exemption at
the end of the 12-month period if the utilization revi ew entity:
1. Makes a determination that the health care provider would
not have met the eighty percent (80%) approval criteria based on a
retrospective review of the claims for the particular service for
which the exemption applies for the previous three (3) months, or
for a longer period if needed to reach a minimum of ten (10) claims
for review;
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2. Provides the health care provider with the information it
relied upon in making its determination to revoke the exemption; and
3. Provides the health care provider a plain language
explanation of how to appeal the decision.
F. An exemption remains i n effect until the 30th day after the
date the utilization review en tity notifies the health care provider
of its determination to revoke the exemption , or if the health care
provider appeals the determination, the fifth day after the
revocation is upheld on appeal.
G. A determination to revoke or deny an exemption must b e made
by a health care provider licensed in Oklahoma of the same or
similar specialty as the health care provider being conside red for
an exemption and have experience in providing the se rvice for which
the potential exemption applies.
H. A utilization review entity must provide a health care
provider that receives an exem ption a notice that includes:
1. A statement that the hea lth care provider qualifies for an
exemption from pre-authorization requirements;
2. A list of services for which the exemption s apply; and
3. A statement of the duration of the exemption.
I. A utilization review entity shall not deny or reduce payment
for a health care service exempted from a prior authorization
requirement under this section, including a health care service
performed or supervised by another health care provider when the
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health care provider who ordered such service received a prior
authorization exemption, unless the rendering health care provi der:
1. Knowingly and materially misrepresented the health care
service in request for payment submitted to the utilization review
entity with the specific intent to deceive an d obtain an unlawful
payment from utilization review entity; or
2. Failed to substantially perform the health care service.
SECTION 8. 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:
Any failure by a utilization review entity to comply with the
deadlines and other requirements specified in this act will result
in any health care services subject to review to be automatically
deemed authorized by the utilization review entity .
SECTION 9. This act shall become effective November 1, 2024.
COMMITTEE REPORT BY: COMMITTEE ON INSURANCE, dated 02/13/2024 - DO
PASS.