Oklahoma 2024 Regular Session

Oklahoma House Bill HB3862 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2	2
3		-	ENGR. H. B. NO. 3862 Page 1 1
	3	+	HB3862 HFLR Page 1
	4	+	BOLD FACE denotes Committee Amendments. 1
4	5		2
5	6		3
6	7		4
7	8		5
8	9		6
9	10		7
10	11		8
11	12		9
12	13		10
13	14		11
14	15		12
15	16		13
16	17		14
17	18		15
18	19		16
19	20		17
20	21		18
21	22		19
22	23		20
23	24		21
24	25		22
25	26		23
26	27		24
27	28
28		-	ENGROSSED HOUSE
29		-	BILL NO. 3862 By: Ford, Sneed, and Sterling
30		-	of the House
	29	+	HOUSE OF REPRESENTATIVES - FLOOR VERSION
31	30
32		-	~~and~~
	31	+	STATE OF OKLAHOMA
33	32
34		-	Standridge of the Senate
	33	+	2nd Session of the 59th Legislature (2024)
	34	+
	35	+	HOUSE BILL 3862 By: Ford
35	36
36	37
37	38
38	39
39	40
40		-	[ health insurance – terms – disclosure and review of
41		-	prior authorization requirements – adverse
42		-	determinations – personnel qualifications –
43		-	consultations – requirements physicians –
44		-	retrospective denial – exemptions – failure to
45		-	comply – codification – effective date ]
	41	+	AS INTRODUCED
	42	+
	43	+	An Act relating to health insurance; defining terms;
	44	+	providing for disclosure and review of prior
	45	+	authorization requirements; providing who shall make
	46	+	adverse determinations ; providing for personnel
	47	+	qualifications; requiring consultations prior to
	48	+	adverse determinations; providing requirements for
	49	+	certain physicians; provi ding for retrospective
	50	+	denial; providing for exemptions; providing for
	51	+	failure to comply; providing for codification; and
	52	+	providing an effective date.
	53	+
	54	+
46	55
47	56
48	57
49	58
50	59		BE IT ENACTED BY THE PEOPLE OF T HE STATE OF OKLAHOMA:
51	60		SECTION 1. NEW LAW A new sect ion of law to be codified
52	61		in the Oklahoma Statutes as Se ction 6570.1 of Title 36, unless there
53	62		is created a duplication in numbering, reads as follows:
54	63		As used in this section:
55	64		1. "Prior authorization" means the process by which utilization
56	65		review entities determine the medical necessity and/or medical
57	66		appropriateness of otherwise covered health care services prior to
58	67		the rendering of such health care services. Prior authorization
59		-	also includes any health insurer 's or utilization review entity 's
60	68
61		-	ENGR. H. B. NO. 3862 Page 2 1
	69	+	HB3862 HFLR Page 2
	70	+	BOLD FACE denotes Committee Amendments. 1
62	71		2
63	72		3
64	73		4
65	74		5
66	75		6
67	76		7
68	77		8
69	78		9
70	79		10
71	80		11
72	81		12
73	82		13
74	83		14
75	84		15
76	85		16
77	86		17
78	87		18
79	88		19
80	89		20
81	90		21
82	91		22
83	92		23
84	93		24
85	94
	95	+	also includes any he alth insurer's or utilization review entity 's
86	96		requirement that an enrollee or health care provider notify the
87	97		health insurer or utilization review entity prior to providing a
88	98		health care service; and
89	99		2. "Utilization review entity " means an individual or entity
90	100		that performs prior authorization for an:
91	101		a. insurer that writes health insurance policies , and
92	102		b. a preferred provider organization, health maintenance
93	103		organization, or exclusive provider organization.
94	104		SECTION 2. NEW LAW A new section of law to be codified
95	105		in the Oklahoma Statut es as Section 6570.2 of Title 36, unless there
96	106		is created a duplication in numbering, reads as follows:
97	107		A. A utilization review entity shall make any current prior
98	108		authorization requirements and restrictions readily accessible on
99	109		its website to enrollees, health care professionals, and the general
100	110		public. This includes the written clinical criteria. Requirements
101	111		shall be described in detail but also in easily understandable
102	112		language.
103	113		B. If a utilization review entity intends either to implement a
104	114		new prior authorization requirement or restriction or amend an
105	115		existing requirement or restriction, the utilization re view entity
106	116		shall ensure that the new or amended requirement is not implemented
107	117		unless the utilization review entity 's website has been updated t o
108	118		reflect the new or amended requirement or restriction .
109	119
110		-	ENGR. H. B. NO. 3862 Page 3 1
	120	+	HB3862 HFLR Page 3
	121	+	BOLD FACE denotes Committee Amendments. 1
111	122		2
112	123		3
113	124		4
114	125		5
115	126		6
116	127		7
117	128		8
118	129		9
119	130		10
120	131		11
121	132		12
122	133		13
123	134		14
124	135		15
125	136		16
126	137		17
127	138		18
128	139		19
129	140		20
130	141		21
131	142		22
132	143		23
133	144		24
134	145
135	146		C. If a utilization review entity intends either to impl ement a
136	147		new prior authorization requirement or restriction or amend an
137	148		existing requirement or restriction, the utilization review entity
138	149		shall provide health care providers of enrollees written not ice of
139		-	the new or amended requirement or ~~restriction~~ no ~~less~~ than sixty
140		-	~~(60)~~ days before the requirement or restriction is implemented.
	150	+	the new or amended requirement or amendment no les s than sixty (60)
	151	+	days before the requirement or restriction is implemented.
141	152		SECTION 3. NEW LAW A new section of law t o be codified
142	153		in the Oklahoma Statutes as Section 6570.3 of Title 36, unless there
143	154		is created a duplication in numbering, reads as follows:
144	155		A. A utilization review entity must ensure that all adverse
145	156		determinations are made by a physician.
146		-	B. The physician must:
147		-	1. Possess a current and valid nonrestricted license to
148		-	practice medicine;
149		-	2. Be of the same specialty as the physician who typically
150		-	manages the medical condition or disease or provides the health care
151		-	service involved in the request;
152		-	3. Have experience treating patients with the medical condition
153		-	or disease for which the health care service is being requested; and
154		-	4. Make the adverse determination under the clinical direction
155		-	of one of the utilization review entity 's medical directors who are
156		-	responsible for the provision of health care services provided to
157		-	enrollees of Oklahoma.
	157	+	1. The physician must:
	158	+	a. possess a current and valid non -restricted license to
	159	+	practice medicine in the state of Oklahoma ,
	160	+	b. be of the same specialty as the physician who
	161	+	typically manages the medical condition or disease or
	162	+	provides the health care service involve d in the
	163	+	request,
	164	+	c. have experience treating patients with the medical
	165	+	condition or disease for which the health care service
	166	+	is being requested, and
	167	+	d. make the adverse determination under the clinical
	168	+	direction of one of the utilization review entity 's
	169	+	medical directors who is responsible for the provision
158	170
159		-	ENGR. H. B. NO. 3862 Page 4 1
	171	+	HB3862 HFLR Page 4
	172	+	BOLD FACE denotes Committee Amendments. 1
160	173		2
161	174		3
162	175		4
163	176		5
164	177		6
165	178		7
166	179		8
167	180		9
168	181		10
169	182		11
170	183		12
171	184		13
172	185		14
173	186		15
174	187		16
175	188		17
176	189		18
177	190		19
178	191		20
179	192		21
180	193		22
181	194		23
182	195		24
183	196
	197	+	of health care services provided to enrollees of
	198	+	Oklahoma.
184	199		SECTION 4. NEW LAW A new section of law to be codified
185	200		in the Oklahoma Statutes as Section 6570.4 of Title 36, unless there
186	201		is created a duplication in numbering, reads as follow s:
187	202		If a utilization review entity is questioning the medical
188	203		necessity of a health care service, the utilization revie w entity
189		-	must notify the enrollee 's physician that ~~the~~ medical necessity is
190		-	~~being~~ questioned. Prior to ~~is suing~~ an adverse determination, the
	204	+	must notify the enrollee 's physician that medical necessity is bei ng
	205	+	questioned. Prior to issuing an adverse determination, the
191	206		enrollee's physician must have the opportunity to discuss the
192		-	medical necessity of the health care service ~~with~~ the ~~physician who~~
193		-	will be responsible for determining ~~authorization of the health care~~
194		-	service under review.
	207	+	medical necessity of the health care service on the telep hone with
	208	+	the physician who will be responsible for determining authorizati on
	209	+	of the health care service under review.
195	210		SECTION 5. NEW LAW A new section of law to be codified
196	211		in the Oklahoma Statutes as Section 6570.5 of Title 36, unless there
197	212		is created a duplication in numbering, reads as follows:
198	213		A. A utilization review entity must ensure that all appeals are
199	214		reviewed by a physician.
200		-	B. The physician must:
201		-	1. Possess a current and valid nonrestricted license to
202		-	practice medicine;
203		-	2. Be currently in active practice in the same or similar
204		-	specialty as a physician who typically manages the medica l condition
205		-	or disease for at least five (5) consecutive years;
206		-	3. Be knowledgeable of, and have experience providing, the
207		-	health care services under appeal;
	215	+	1. The physician must:
	216	+	a. possess a current and valid non -restricted license to
	217	+	practice medicine in Oklahoma,
	218	+	b. be currently in active practice in the same or similar
	219	+	specialty as a physician who typically manages the
208	220
209		-	ENGR. H. B. NO. 3862 Page 5 1
	221	+	HB3862 HFLR Page 5
	222	+	BOLD FACE denotes Committee Amendments. 1
210	223		2
211	224		3
212	225		4
213	226		5
214	227		6
215	228		7
216	229		8
217	230		9
218	231		10
219	232		11
220	233		12
221	234		13
222	235		14
223	236		15
224	237		16
225	238		17
226	239		18
227	240		19
228	241		20
229	242		21
230	243		22
231	244		23
232	245		24
233	246
234		-	4. Not be employed by a utilization review entity or be under
235		-	contract with the utilization revi ew entity other than to
236		-	participate in one or more of the utilization review entity 's health
237		-	care provider networks or to perform reviews of appeals, or
238		-	otherwise have any financial interest in the outcome of the appeal;
239		-	5. Not have been directly involved in making the adverse
240		-	determination; and
241		-	6. Consider all known clinical aspects of the health care
242		-	service under review, including, but not limited to, a review of all
243		-	pertinent medical records provided to the utilization review entity
244		-	by the enrollee's health care provider, any relevant records
245		-	provided to the utilization review entity by a health care facility,
246		-	and any medical literature provided to the utilization review entity
247		-	by the health care provider.
	247	+	medical condition or disease for at least five (5)
	248	+	consecutive years,
	249	+	c. be knowledgeable of, and have experience providing,
	250	+	the health care services under appeal ,
	251	+	d. not be employed by a utilization revie w entity or be
	252	+	under contract with the utilization review entity
	253	+	other than to participate in one or more of the
	254	+	utilization review entity 's health care provider
	255	+	networks or to perform reviews of appeals, or
	256	+	otherwise have any financial interest in the out come
	257	+	of the appeal,
	258	+	e. not have been directly involved in making the adverse
	259	+	determination, and
	260	+	f. consider all known clinical aspects of the health
	261	+	care, service under review, including , but not limited
	262	+	to, a review of all pertinent medical records provi ded
	263	+	to the utilization review entity by the enrollee 's
	264	+	health care provider, any relevant records provided to
	265	+	the utilization review entity by a health care
	266	+	facility, and any medical literature provided to the
	267	+	utilization review entity by the health care p rovider.
248	268		SECTION 6. NEW LAW A new section of law to be codified
249	269		in the Oklahoma Statutes as Section 6570.6 of Title 36, unless there
250	270		is created a duplication in numbering, reads as follows:
251		-	A. A utilization review entity may not revoke, limit,
252		-	condition, or restrict a prior authoriz ation if care is provided
253		-	within forty-five (45) business days from the date the health care
254		-	provider received the prior authorization.
255		-	B. In the case of preventive care that has prior authorization
256		-	approval, if it has been determined medically necessary by the
257		-	medical provider that additional preventive care is needed, it shall
258	271
259		-	ENGR. H. B. NO. 3862 Page 6 1
	272	+	HB3862 HFLR Page 6
	273	+	BOLD FACE denotes Committee Amendments. 1
260	274		2
261	275		3
262	276		4
263	277		5
264	278		6
265	279		7
266	280		8
267	281		9
268	282		10
269	283		11
270	284		12
271	285		13
272	286		14
273	287		15
274	288		16
275	289		17
276	290		18
277	291		19
278	292		20
279	293		21
280	294		22
281	295		23
282	296		24
283	297
	298	+	A. A utilization review entity m ay not revoke, limit, condition
	299	+	or restrict a prior authorization if care i s provided within forty-
	300	+	five (45) business days from the date the health care provider
	301	+	received the prior authorization.
	302	+	B. In the case of preventive care that has prior authorization
	303	+	approval, if it has been determined medically necessary by the
	304	+	medical provider that additional preventive care is needed, it shall
284	305		be covered under the initial pre -authorization. For any
285	306		subsequently provided prevent ive care covered by the initial pre -
286	307		authorization, it must be in connection to care furnished by the
287	308		medical provider. Any care provided to an enrollee that is not in
288	309		connection to pre-authorized preventive care shall need to receive
289	310		pre-authorization approval.
290		-	C. A utilization review entity that has made an adverse
291		-	determination of both a reques t for prior authorization and a
292		-	subsequent appeal by an enrollee's health care provider may be
293		-	subject to medical malpractice if it is found that the medical care
294		-	furnished in accordance with a utilization review entity's approval
295		-	of medical care deviated from accepted norms of practice in the
296		-	medical community, the recommendation of an enrollee's health care
297		-	provider, and causes an injury to the enrollee. A utilization
298		-	review entity shall only be found liable for medical malpractice if
299		-	documentation is provided that shows a utilization review entity
300		-	undermined the judgment of the enrollee's medical provider and all
301		-	relevant information utilized to support the initial request for
302		-	prior authorization and appeal of the adverse determination.
303		-	D. Nothing in this section shall be construed to require pre -
	311	+	C. Nothing in this section s hall be construed to require pre-
304	312		authorization approval of care that is already exempted from a pre -
305	313		authorization approval.
	314	+	SECTION 7. NEW LAW A new section of law to be codified
	315	+	in the Oklahoma Statutes as Section 6570.7 of Title 36, unless there
	316	+	is created a duplication in numbering, reads as fol lows:
	317	+	A. A utilization review entity may not require a health care
	318	+	provider to complete a prior authorization for a health care service
	319	+	in order for the enrollee to whom the service is be ing provided to
	320	+	receive coverage if in the most recent 12 -month period, the
	321	+	utilization review entity has approved or would have approved not
306	322
307		-	ENGR. H. B. NO. 3862 Page 7 1
	323	+	HB3862 HFLR Page 7
	324	+	BOLD FACE denotes Committee Amendments. 1
308	325		2
309	326		3
310	327		4
311	328		5
312	329		6
313	330		7
314	331		8
315	332		9
316	333		10
317	334		11
318	335		12
319	336		13
320	337		14
321	338		15
322	339		16
323	340		17
324	341		18
325	342		19
326	343		20
327	344		21
328	345		22
329	346		23
330	347		24
331	348
332		-	SECTION 7. NEW LAW A new section of law to be codified
333		-	in the Oklahoma Statutes as Section 6570.7 of Title 3 6, unless there
334		-	is created a duplication in numbering, reads as follows:
335		-	A. A utilization review entity may not require a health care
336		-	provider to complete a prior authorization for a heal th care service
337		-	in order for the enrollee to whom the service is bei ng provided to
338		-	receive coverage if in the most recent twelve -month period, the
339		-	utilization review entity has approved or would have approved not
340	349		less than eighty percent (80%) of the prior authorization requests
341	350		submitted by the health care provider for that health care service.
342	351		B. A utilization review entity may evaluate wh ether a health
343	352		care provider continues to qualify for exemptions as described in
344		-	subsection A ~~of this section~~ not ~~mor e~~ than once every twelve (12)
345		-	~~months. Nothing~~ in this section ~~requi res~~ a utilization ~~review~~
346		-	~~entity to evaluate an~~ existing exemption or prevents a ~~utilization~~
347		-	~~review entity from~~ establishing a longer exemption period.
	353	+	subsection A not more than once every twelve (12) months. Nothing
	354	+	in this section requires a utilization re view entity to evaluate an
	355	+	existing exemption or prevents a utilizat ion review entity from
	356	+	establishing a longer exemption period.
348	357		C. A health care provider is not required to request an
349	358		exemption in order to qualify for an exemption.
350	359		D. A health care provider who does not receive an exemption may
351	360		request from the utili zation review entity at any time, but not more
352	361		than once per year per service, evidence to support the utilization
353	362		review entity's decision. A health care provider may appeal a
354	363		utilization review entity's decision to deny an exemption.
	364	+	E. A utilization review entity may only revoke an exemption at
	365	+	the end of the 12-month period if the utilization revi ew entity:
	366	+	1. Makes a determination that the health care provider would
	367	+	not have met the eighty percent (80%) approval criteria based on a
	368	+	retrospective review of the claims for the particular service for
	369	+	which the exemption applies for the previous three (3) months, or
	370	+	for a longer period if needed to reach a minimum of ten (10) claims
	371	+	for review;
355	372
356		-	ENGR. H. B. NO. 3862 Page 8 1
	373	+	HB3862 HFLR Page 8
	374	+	BOLD FACE denotes Committee Amendments. 1
357	375		2
358	376		3
359	377		4
360	378		5
361	379		6
362	380		7
363	381		8
364	382		9
365	383		10
366	384		11
367	385		12
368	386		13
369	387		14
370	388		15
371	389		16
372	390		17
373	391		18
374	392		19
375	393		20
376	394		21
377	395		22
378	396		23
379	397		24
380	398
381		-	E. A utilization review entity may only revoke an exemption at
382		-	the end of the twelve -month period if the utilization re view entity:
383		-	1. Makes a determination that the health care provider would
384		-	not have met the eighty percent (80%) approval criteria based on a
385		-	retrospective review of the claims for the particular service for
386		-	which the exemption applies for the previous thr ee (3) months, or
387		-	for a longer period if needed to reach a minimum o f ten claims for
388		-	review;
389	399		2. Provides the health care provider with the information it
390	400		relied upon in making its determination to revoke the exemption; and
391	401		3. Provides the health care provider a plain language
392	402		explanation of how to appeal the decision.
393		-	F. An exemption remains in effect until the ~~thirtieth~~ day after
394		-	~~the~~ date the utilization review ~~entity~~ notifies the health care
395		-	~~provider~~ of its determination to revoke the exemption, or if the
396		-	~~health care~~ provider appeals the determination, the fifth day ~~af ter~~
397		-	~~the~~ revocation is upheld on appeal.
	403	+	F. An exemption remains i n effect until the 30th day after the
	404	+	date the utilization review en tity notifies the health care provider
	405	+	of its determination to revoke the exemption , or if the health care
	406	+	provider appeals the determination, the fifth day after the
	407	+	revocation is upheld on appeal.
398	408		G. A determination to revoke or deny an exemption must b e made
399		-	by a health care provider of the same or ~~similar specialty as the~~
400		-	health care provider being ~~considered~~ for ~~an exemption and have~~
401		-	experience in ~~providin g~~ the ~~service~~ for which ~~the potential~~
402		-	exemption applies.
	409	+	by a health care provider licensed in Oklahoma of the same or
	410	+	similar specialty as the health care provider being conside red for
	411	+	an exemption and have experience in providing the se rvice for which
	412	+	the potential exemption applies.
403	413		H. A utilization review entity must provide a health care
404	414		provider that receives an exem ption a notice that includes:
	415	+	1. A statement that the hea lth care provider qualifies for an
	416	+	exemption from pre-authorization requirements;
	417	+	2. A list of services for which the exemption s apply; and
	418	+	3. A statement of the duration of the exemption.
	419	+	I. A utilization review entity shall not deny or reduce payment
	420	+	for a health care service exempted from a prior authorization
	421	+	requirement under this section, including a health care service
	422	+	performed or supervised by another health care provider when the
405	423
406		-	ENGR. H. B. NO. 3862 Page 9 1
	424	+	HB3862 HFLR Page 9
	425	+	BOLD FACE denotes Committee Amendments. 1
407	426		2
408	427		3
409	428		4
410	429		5
411	430		6
412	431		7
413	432		8
414	433		9
415	434		10
416	435		11
417	436		12
418	437		13
419	438		14
420	439		15
421	440		16
422	441		17
423	442		18
424	443		19
425	444		20
426	445		21
427	446		22
428	447		23
429	448		24
430	449
431		-	1. A statement that the health care provider qualifies for an
432		-	exemption from pre-authorization requirements;
433		-	2. A list of services for which the exemptions apply; and
434		-	3. A statement of the duration of the exemption.
435		-	I. A utilization review entity shall not deny or reduce payment
436		-	for a health care service exempted from a prior auth orization
437		-	requirement under this section, including a health care service
438		-	performed or supervised by another health care provider when the
439	450		health care provider who ordered such service received a prior
440	451		authorization exemption, unless the rendering health care provi der:
441	452		1. Knowingly and materially misrepresented the health care
442	453		service in request for payment submitted to the utilization review
443	454		entity with the specific intent to deceive an d obtain an unlawful
444	455		payment from utilization review entity; or
445	456		2. Failed to substantially perform the health care service.
446	457		SECTION 8. NEW LAW A new section of law to be codified
447	458		in the Oklahoma Statutes as Section 6570.8 of Title 36, unless there
448	459		is created a duplication in numbering, reads as follows:
449	460		Any failure by a utilization review entity to comply with the
450	461		deadlines and other requirements specified in this act will result
451	462		in any health care services subject to review to be automatically
452	463		deemed authorized by the utilization review entity .
453	464		SECTION 9. This act shall become effective November 1, 2024.
454	465
455		-	ENGR. H. B. NO. 3862 Page 10 1
456		-	2
457		-	3
458		-	4
459		-	5
460		-	6
461		-	7
462		-	8
463		-	9
464		-	10
465		-	11
466		-	12
467		-	13
468		-	14
469		-	15
470		-	16
471		-	17
472		-	18
473		-	19
474		-	20
475		-	21
476		-	22
477		-	23
478		-	24
479		-
480		-	Passed the House of Representatives the 12th day of March, 2024.
481		-
482		-
483		-
484		-
485		-	Presiding Officer of the House
486		-	of Representatives
487		-
488		-
489		-
490		-	Passed the Senate the ___ day of __________, 2024.
491		-
492		-
493		-
494		-
495		-	Presiding Officer of the Senate
496		-
497		-
	466	+	COMMITTEE REPORT BY: COMMITTEE ON INSURANCE, dated 02/13/2024 - DO
	467	+	PASS.