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STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024)
SENATE BILL 1972 By: Jett
AS INTRODUCED
An Act relating to emergency care; defining terms;
establishing requirements for certain utilization
review; establishing requirements rel ating to adverse
determinations; construing provision; providing for
codification; and providing an effective date .
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be cod ified
in the Oklahoma Statutes as Section 6582 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. As used in this section:
1. “Adverse determination ” means a determination by a health
carrier or its designee utilization review organization 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 m eet the health carrier ’s
requirements for medical nec essity, appropriateness, health care
setting, level of care , or effectiveness, and the requested service
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or payment for the service is therefore denied, reduced , or
terminated;
2. “Emergency care” means health care services provided in a
general medical surgical hospital, critical access hospital, or
emergency hospital, as such terms are defined in Section 1 -701 of
Title 63 of the Oklahoma Statutes, that is licensed by the State
Department of Health to evaluate and stabilize medical conditions of
a recent and onset severity, including severe pain, regardless of
the final diagnosis that is given, that would lead a prudent
layperson possessing an average knowledge o f medicine and healt h to
believe that the individual’s condition, sickness, or injury is of
such a nature that failure to get immediate medical care could:
a. place the individual ’s health in serious jeopardy,
b. result in serious impairment, dysfunction, or
disfigurement of a bodil y function, bodily or gan, or
bodily part, or
c. for pregnant women, result in serious jeopardy to the
health of the fetus; and
3. “Utilization review” means a system for prospectively,
concurrently, and retrospectively reviewing the appropriate and
efficient allocation of hospital resources and medical services
given or proposed to be given to a patient or group of patients. It
does not include an insurer ’s normal claim review process to
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determine compliance with the s pecific terms and conditions of the
insurance policy.
B. Utilization review of an emergency ca re claim shall be
performed by a physician who:
1. Possesses a current and valid non-restricted license to
practice medicine in this state;
2. Is of the same specialty as the physician who typically
manages the medical condition or disease or provides the health c are
service; and
3. Has experience treating patients with the medical condition
or disease.
C. A physician conducting a utilization review under this
section shall review the enrollee’s medical records prior to making
an adverse determination regarding payment for an emergency care
claim. No adverse determination may be made based on the final
diagnosis that is given, including the classification under current
procedural terminology or Internal Classification of Diseases code.
D. Nothing in this section may be construed as authorizing
utilization review of emergency care when otherwise prohibited by
law.
SECTION 2. This act shall become effective November 1, 2024.
59-2-2375 RD 1/18/2024 1:50:50 PM