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0 chapters · 1,670 sections in this title.
36 O.S. § 6475.11 Binding power of external review decision
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A. An external review decision is binding on the health carrier except to the extent the health carrier has other remedies available under applicable state law. B. An external review decision is binding on the covered person except to the extent the covered person has other remed…
36 O.S. § 6475.12 Approval of independent review organizations
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A. The Insurance Commissioner shall approve independent review organizations eligible to be assigned to conduct external reviews under the Uniform Health Carrier External Review Act. B. In order to be eligible for approval by the Commissioner under this section to conduct externa…
36 O.S. § 6475.13 Eligibility requirements
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A. To be approved under Section 6475.12 of this title to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review pro…
36 O.S. § 6475.14 Employee liability
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No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions perfor…
36 O.S. § 6475.15 Written records
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A. 1. An independent review organization assigned pursuant to Section 6475.8, 6475.9, or 6475.10 of this title to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted a…
36 O.S. § 6475.16 Cost of independent review organization
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The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the independent review organization for conducting the external review. Added by Laws 2011, c. 278, § 50 and Laws 2011, c. 360, § 40. NOTE: Law…
36 O.S. § 6475.17 Description of external review procedures
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A. 1. Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons. 2. The disclosure required by paragraph 1 of th…
36 O.S. § 6475.2 Purpose
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The purpose of the Uniform Health Carrier External Review Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adv…
36 O.S. § 6475.3 Definitions
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For purposes of the Uniform Health Carrier External Review Act: 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 cove…
36 O.S. § 6475.4 Applicability of act
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A. Except as provided in subsection B of this section, the Uniform Health Carrier External Review Act shall apply to all health carriers. B. The provisions of the Uniform Health Carrier External Review Act shall not apply to a policy or certificate that provides coverage only for…
36 O.S. § 6475.5 External review
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A. 1. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to Section 6475.8, 6475.9, or 6475.10 of this title and include the appropriate statements and information set forth in subsectio…
36 O.S. § 6475.6 Form of external review requests
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A. 1. Except for a request for an expedited external review as set forth in Section 6475.9 of this title, all requests for external review shall be made in writing to the Insurance Commissioner. 2. The Commissioner may prescribe by rule the form and content of external review req…
36 O.S. § 6475.7 External review procedure
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A. 1. Except as provided in subsection B of this section, a request for an external review pursuant to Section 6475.8, 6475.9, or 6475.10 of this title shall not be made until the covered person has exhausted the health carrier's internal grievance process. 2. A covered person sh…
36 O.S. § 6475.8 Receipt of request for external review
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A. 1. Within four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Section 6475.5 of this title, a covered person or the covered person's authorized representative may file a request for an external review wit…
36 O.S. § 6475.9 Circumstances when external review request can be made
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A. Except as provided in subsection F of this section, a covered person or the covered person's authorized representative may make a request for an expedited external review with the Insurance Commissioner at the time the covered person receives: 1. An adverse determination if: a…
36 O.S. § 650 Competition with Nine-One-One system prohibited
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Insurers, nonprofit health service plans, and health maintenance organizations shall not establish or promote an emergency medical response, triage, or transportation system in competition with or in substitution of the Nine-One-One system. Insurers, nonprofit health service plan…
36 O.S. § 6511 Short title
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Sections 6511 through 6518 and Sections 5 through 15 of this act shall be known and may be cited as the "Small Employer Health Insurance Reform Act". Added by Laws 1992, c. 329, § 1, eff. Sept. 1, 1992. Amended by Laws 1994, c. 211, § 1, eff. July 1, 1994.
36 O.S. § 6512 Definitions
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As used in the Small Employer Health Insurance Reform Act: 1. "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the Insurance Commissioner that a small employer carrier is in compliance with the …
36 O.S. § 6513 Application of act to certain group health benefit plans
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A. Except as otherwise provided in this section and in Section 3 of this act, the Small Employer Health Insurance Reform Act shall apply to any group health benefit plan that provides coverage to two (2) or more eligible employees of a small employer in this state and to individu…
36 O.S. § 6514 Classes of business - Criteria to establish - Number -
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Rules - Additional classes. A. A small employer carrier may establish a class of business only to reflect substantial differences in expected claims experience or administrative costs related to the following reasons: 1. The small employer carrier uses more than one type of syste…
36 O.S. § 6515 Premium rates
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A. Premium rates for health benefit plans subject to the Small Employer Health Insurance Reform Act shall be subject to the following provisions: 1. The rate manual developed for use by a small employer carrier shall be filed and approved by the Insurance Commissioner prior to us…
36 O.S. § 6516 Renewability of health benefit plans - Election not to
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renew - Geographic service area. A. A health benefit plan subject to this act shall be renewable with respect to all eligible employees and dependents, at the option of the small employer, except in any of the following cases: 1. Nonpayment of the required premiums; 2. Fraud or m…
36 O.S. § 6517 Disclosures required of small employer carriers
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In connection with the offering for sale of any health benefit plan to a small employer, a small employer carrier shall make a reasonable disclosure, as part of its solicitation and sales materials, of all of the following: 1. The extent to which premium rates for a specified sma…
36 O.S. § 6518 Maintenance and disclosure of certain information and
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documents - Filing of actuarial certification. A. Each small employer carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate…
36 O.S. § 6519 Basic and standard health benefit plans - Condition of
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transacting business - Filing with Commissioner - Required compliance with certain provisions - Exceptions. A. 1. As a condition of transacting business in this state with small employers, every small employer carrier shall actively offer to small employers the health benefit pla…
36 O.S. § 6526 Rulemaking
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The Insurance Commissioner may promulgate rules in accordance with Article I of the Administrative Procedures Act, Sections 250.2 through 323 of Title 75 of the Oklahoma Statutes, for the implementation and administration of the Small Employer Health Insurance Reform Act. Added b…
36 O.S. § 6527 Marketing of health benefit plan coverage
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A. Each small employer carrier shall actively market health benefit plan coverage to all eligible small employers in this state. B. 1. Except as provided in paragraph 2 of this subsection, no small employer carrier or agent shall, directly or indirectly, engage in the following a…
36 O.S. § 6528 Reissuance of certain terminated coverage
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The Insurance Commissioner may promulgate rules to require small employer carriers, as a condition of transacting business with small employers in this state after the effective date of this act, to reissue a health benefit plan to any small employer whose health benefit plan has…
36 O.S. § 6529 Suspension of implementation if inconsistent with federal
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law. In the event that the Congress of the United States enacts laws legally inconsistent with any portion of this act, the Insurance Commissioner may suspend implementation of such inconsistent portion of this act. In such case, the Commissioner shall notify the Governor, Presid…
36 O.S. § 6530 Bona fide association health plans
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A. "Bona fide association" means any association that has a current form M-1 filed with and accepted by the United States Department of Labor showing Oklahoma as the state of operation and: 1. Is formed under a pathway established in accordance with the applicable provisions of 2…
36 O.S. § 6530.1 Oklahoma Individual Health Insurance Market
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Stabilization Act – Legislative intent. This act shall be known and may be cited as the "Oklahoma Individual Health Insurance Market Stabilization Act". It is the intent of the Legislature to provide payments to health insurance plans with respect to claims for eligible individua…
36 O.S. § 6530.10 Application for waiver pursuant to Patient Protection
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and Affordable Care Act. The Oklahoma Secretary of Health and Human Services may apply to the United States Secretary of Health and Human Services for a waiver pursuant to Section 1332 of the Patient Protection and Affordable Care Act (42 U.S.C., Section 18052), "1332 State Innov…
36 O.S. § 6530.2 Definitions
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As used in the Oklahoma Individual Health Insurance Market Stabilization Act: 1. "Agent" means any person who is licensed to sell health insurance in this state; 2. "Board" means the Board of Directors of the Oklahoma Individual Health Insurance Market Stabilization Program; 3. "…
36 O.S. § 6530.3 Eligible persons
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Except as otherwise provided in this section, any person who is qualified for and enrolled in coverage through the market and is a permanent resident of the State of Oklahoma shall be eligible for coverage under the Oklahoma Individual Health Insurance Market Stabilization Progra…
36 O.S. § 6530.4 Oklahoma Individual Health Insurance Market
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Stabilization Program. A. There is hereby created a nonprofit legal entity to be known as the "Oklahoma Individual Health Insurance Market Stabilization Program". B. 1. The Program shall operate under the management of a nine-member Board of Directors appointed by the Insurance C…
36 O.S. § 6530.5 Board of Directors – Duties – Sunset of Program
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A. The Board of Directors of the Oklahoma Individual Health Insurance Market Stabilization Program shall: 1. Develop, implement and administer the Program. Implementation of the Program shall be contingent upon Oklahoma's approval for and receipt of federal funds to implement and…
36 O.S. § 6530.6 Board of Directors – Powers
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The Board may: 1. Exercise powers granted to insurers under the laws of this state; 2. Sue or be sued; and 3. Request the Insurance Commissioner to check the reports, records, books and papers of the Insurance Department to determine the financial condition of an insurer for purp…
36 O.S. § 6530.9 Unfair practice – Separating individual employees from
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group health insurance coverage. It shall constitute an unfair practice for the purposes of Sections 1201 through 1220 of Title 36 of the Oklahoma Statutes for an insurer, insurance agent, insurance broker or third-party administrator to refer an individual employee to the Progra…
36 O.S. § 6551 Short title
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Sections 1 through 16 of this act shall constitute a part of the Insurance Code and shall be known and may be cited as the "Hospital and Medical Services Utilization Review Act". Added by Laws 1991, c. 294, § 1, eff. Nov. 1, 1991.
36 O.S. § 6552 Definitions
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As used in the Hospital and Medical Services Utilization Review Act: 1. "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 gi…
36 O.S. § 6553 Private review agents - Certification required -
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Exemptions. A. A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case-by-case basis shall not conduc…
36 O.S. § 6554 Exemptions - Review of patients eligible under Social
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Security - In-house utilization review. A. The Insurance Commissioner shall waive the requirements of the Hospital and Medical Services Utilization Review Act for the activities of a private review agent in connection with a contract with the federal or state government for utili…
36 O.S. § 6555 Rules - Forms - Issuance of certificate - Reporting
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requirements - Confidentiality. A. The Insurance Commissioner may promulgate and adopt rules to implement the provisions of this section. B. The Commissioner shall develop standardized forms for registration, performing and implementing certification requirements pursuant to the …
36 O.S. § 6556 Health insurance plans - Certification or contract with
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certified private review agent - Exceptions. Every health insurance plan which proposes to administer a health benefits program that provides for the coverage of hospital and/or medical benefits and the utilization review of those benefits shall: 1. Be certified in accordance wit…
36 O.S. § 6557 Application for certificate
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A. An applicant for a certificate shall: 1. Submit an application to an Insurance Commissioner; and 2. Pay to the Commissioner an application fee in an amount of Five Hundred Dollars ($500.00), which shall be sufficient to pay for the administrative cost of the certification prog…
36 O.S. § 6558 Information required to be submitted by private review
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agents. In conjunction with an application for a certificate, the private review agent shall submit information that the Insurance Commissioner requires, including, but not limited to: 1. A utilization review plan that includes: a. an adequate summary description of review standa…
36 O.S. § 6559 Information required to be submitted relating to in-house
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review. A. Insurance companies and not-for-profit hospital services and medical indemnity plans licensed by the Commissioner that perform in-house utilization review shall submit to the Commissioner the following information regarding utilization review: 1. A utilization review p…
36 O.S. § 6560 Expiration of certificate - Renewal
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A. A certificate expires on the first anniversary of its effective date unless the certificate is renewed for a one-year term as provided in this section. B. Before the certificate expires, a certificate may be renewed for an additional one-year term, if the applicant: 1. Otherwi…
36 O.S. § 6561 Refusal to issue or renew or suspension or revocation of
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certificate - Hearing - Appeal. A. The Insurance Commissioner may refuse to issue or renew or may suspend or revoke a certificate if the holder does not comply with performance assurances under this section, violates any provision of the Hospital and Medical Services Utilization …
36 O.S. § 6562 Disclosure or publication of confidential medical
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information. A private review agent shall not disclose or publish individual medical records or any other confidential medical information obtained in the performance of utilization review activities without the appropriate procedures for protecting the patient's confidentiality.…