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53	53	STATE OF OKLAHOMA
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55	55	2nd Session of the 59th Legislature (2024)
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57	57	SENATE BILL 1972 By: Jett
58	58
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63	63	AS INTRODUCED
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65	65	An Act relating to emergency care; defining terms;
66	66	establishing requirements for certain utilization
67	67	review; establishing requirements rel ating to adverse
68	68	determinations; construing provision; providing for
69	69	codification; and providing an effective date .
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75	75	BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
76	76	SECTION 1. NEW LAW A new section of law to be cod ified
77	77	in the Oklahoma Statutes as Section 6582 of Title 36, unless there
78	78	is created a duplication in numbering, reads as follows:
79	79	A. As used in this section:
80	80	1. “Adverse determination ” means a determination by a health
81	81	carrier or its designee utilization review organization that an
82	82	admission, availability of care, continued stay , or other health
83	83	care service that is a covered benefit has been reviewed and, based
84	84	upon the information provided, does not m eet the health carrier ’s
85	85	requirements for medical nec essity, appropriateness, health care
86	86	setting, level of care , or effectiveness, and the requested service
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138	138	or payment for the service is therefore denied, reduced , or
139	139	terminated;
140	140	2. “Emergency care” means health care services provided in a
141	141	general medical surgical hospital, critical access hospital, or
142	142	emergency hospital, as such terms are defined in Section 1 -701 of
143	143	Title 63 of the Oklahoma Statutes, that is licensed by the State
144	144	Department of Health to evaluate and stabilize medical conditions of
145	145	a recent and onset severity, including severe pain, regardless of
146	146	the final diagnosis that is given, that would lead a prudent
147	147	layperson possessing an average knowledge o f medicine and healt h to
148	148	believe that the individual’s condition, sickness, or injury is of
149	149	such a nature that failure to get immediate medical care could:
150	150	a. place the individual ’s health in serious jeopardy,
151	151	b. result in serious impairment, dysfunction, or
152	152	disfigurement of a bodil y function, bodily or gan, or
153	153	bodily part, or
154	154	c. for pregnant women, result in serious jeopardy to the
155	155	health of the fetus; and
156	156	3. “Utilization review” means a system for prospectively,
157	157	concurrently, and retrospectively reviewing the appropriate and
158	158	efficient allocation of hospital resources and medical services
159	159	given or proposed to be given to a patient or group of patients. It
160	160	does not include an insurer ’s normal claim review process to
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212	212	determine compliance with the s pecific terms and conditions of the
213	213	insurance policy.
214	214	B. Utilization review of an emergency ca re claim shall be
215	215	performed by a physician who:
216	216	1. Possesses a current and valid non-restricted license to
217	217	practice medicine in this state;
218	218	2. Is of the same specialty as the physician who typically
219	219	manages the medical condition or disease or provides the health c are
220	220	service; and
221	221	3. Has experience treating patients with the medical condition
222	222	or disease.
223	223	C. A physician conducting a utilization review under this
224	224	section shall review the enrollee’s medical records prior to making
225	225	an adverse determination regarding payment for an emergency care
226	226	claim. No adverse determination may be made based on the final
227	227	diagnosis that is given, including the classification under current
228	228	procedural terminology or Internal Classification of Diseases code.
229	229	D. Nothing in this section may be construed as authorizing
230	230	utilization review of emergency care when otherwise prohibited by
231	231	law.
232	232	SECTION 2. This act shall become effective November 1, 2024.
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234	234	59-2-2375 RD 1/18/2024 1:50:50 PM

Oklahoma 2024 Regular Session

Oklahoma Senate Bill SB1972 Compare Versions