Title 36 — Title 36 — Insurance
0 chapters · 2,025 sections in this title.
36 O.S. § 6533 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6533 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6534 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6534 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6535 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6535 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6536 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6536 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6537 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6537 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6538 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6538 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6538.1 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6538.1 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6539 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6539 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6540 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6540 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6541 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6541 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6542 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6542 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6543 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6543 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6544 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
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36 O.S. § 6544 Repealed by Laws 2014, c. 389, § 3, eff. Jan. 1, 2017
36 O.S. § 6545 Repealed by Laws 2014, c. 389, § 4, eff. Dec. 1, 2017
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36 O.S. § 6545 Repealed by Laws 2014, c. 389, § 4, eff. Dec. 1, 2017
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.…
36 O.S. § 6563 Liability - Construction of act
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Nothing in the Hospital and Medical Services Utilization Review Act shall be deemed to reduce or expand the liability of any person or entity for any actions or activities with respect to utilization review. Added by Laws 1991, c. 294, § 13, eff. Nov. 1, 1991.
36 O.S. § 6564 Examination of affairs of private review agent
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Whenever the Insurance Commissioner deems it to be prudent for the benefit of the insureds, health care providers, or insurers, the Commissioner or any person designated by the Commissioner may visit and examine the affairs of any private review agent to determine if the agent is…
36 O.S. § 6565 Civil fines
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For any violation of the provisions of the Hospital and Medical Services Utilization Review Act or any rule adopted pursuant thereto, the Insurance Commissioner may, upon notice and hearing, subject a person or entity to a civil fine of not less than One Hundred Dollars ($100.00)…
36 O.S. § 6566 Repealed by Laws 2009, c. 432, § 27, eff. July 1, 2009
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36 O.S. § 6566 Repealed by Laws 2009, c. 432, § 27, eff. July 1, 2009
36 O.S. § 6570.1 Definitions
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As used in this act: 1. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon th…
36 O.S. § 6570.10 Prior authorization granted under former health plan —
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Time frame to honor — Review. A. On receipt of information documenting a prior authorization from the enrollee or from the enrollee's health care provider, a utilization review entity shall honor a prior authorization granted to an enrollee from a previous utilization review enti…
36 O.S. § 6570.11 Severability
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If any provision of this act or the application thereof to any person or circumstance is held invalid, such invalidity shall not affect other provisions or applications of the act which can be given effect without the invalid provision or application, and to this end, the provisi…
36 O.S. § 6570.2 Utilization review entities — Duties
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A utilization review entity shall make any current prior authorization requirements and restrictions, including written clinical criteria, readily accessible on its website to enrollees and health care providers. Prior authorization requirements shall be described in detail but a…
36 O.S. § 6570.3 Adverse determinations to be made by physician or
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licensed mental health professional. A utilization review entity shall ensure that all adverse determinations are made by a physician or licensed mental health professional. The physician or licensed mental health professional shall: 1. Possess a current and valid nonrestricted l…
36 O.S. § 6570.4 Appeals to be reviewed by physician or licensed mental
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health professional. A utilization review entity shall ensure that all appeals are reviewed by a physician or licensed mental health professional. The physician or licensed mental health professional shall: 1. Possess a current and valid unrestricted license in any United States …
36 O.S. § 6570.5 Prior Authorization Application Programming Interface
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requirement. A. For plan years beginning on or after January 1, 2027, a health benefit plan must implement and maintain a Prior Authorization Application Programming Interface (API), as described in 45 C.F.R. Part 156. B. By July 1, 2027, health care providers must have electroni…
36 O.S. § 6570.50 Definitions
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As used in this act: 1. "Adverse determination" means a determination by a health carrier, pharmacy benefits manager (PBM), or its designee utilization review entity that a prescription drug that is a covered benefit has been reviewed and, based upon the information provided, doe…
36 O.S. § 6570.51 Online accessibility for prescription drug prior
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authorization requirements, restrictions, and formularies. A utilization review entity shall make any current prescription drug prior authorization requirements and restrictions, including written clinical criteria, readily accessible on its website to enrollees and health care p…
36 O.S. § 6570.52 Adverse determinations to include alternative
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prescription drugs — Qualifications of reviewers. A utilization review entity shall ensure that all adverse determinations include alternative prescription drugs covered by the health plan's formulary and are made by a physician, pharmacist, or licensed mental health professional…
36 O.S. § 6570.53 Review of appeals — Qualifications of reviewers
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A utilization review entity shall ensure that all appeals are reviewed by a physician, pharmacist, or licensed mental health professional. The physician, pharmacist, or licensed mental health professional shall: 1. Possess a current and valid unrestricted license in any United St…
36 O.S. § 6570.54 Timeframes for prior authorizations
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A. If a utilization review entity requires prior authorization of a prescription drug, the utilization review entity shall make a prior authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the prior authorization or adverse det…
36 O.S. § 6570.55 Prior authorization not required for emergency
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services. A utilization review entity shall not require prior authorization for prescription drugs administered as a part of the provision of emergency health care services. Added by Laws 2025, c. 447, § 7, eff. Nov. 1, 2025.
36 O.S. § 6570.56 Timeframe for validity of prior authorizations for
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chronic conditions. A. If a prior authorization is required for a prescription drug for the treatment of a chronic condition of an enrollee, and the enrollee remains on the same health plan, then the prior authorization shall remain valid for three (3) years from the date the hea…
36 O.S. § 6570.57 Continuity of prior authorizations during health plan
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changes. A. On receipt of information documenting a prior authorization from the enrollee or from the enrollee's health care provider, a utilization review entity shall honor a prior authorization granted to an enrollee from a previous utilization review entity for at least the i…
36 O.S. § 6570.58 Violations — Penalties
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A. 1. The Insurance Commissioner may, if the Commissioner finds that any person or organization has violated the provisions of this act, impose a penalty of not more than Five Thousand Dollars ($5,000.00) for each such violation. Such penalties may be in addition to any other pen…
36 O.S. § 6570.59 Application to Oklahoma Medicaid State Plan
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This act shall apply to the Oklahoma Medicaid State Plan. Added by Laws 2025, c. 447, § 11, eff. Nov. 1, 2025.
36 O.S. § 6570.6 Time frame to make prior authorization or adverse
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determination. A. If a utilization review entity requires prior authorization of a health care service, the utilization review entity must make a prior authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the prior authorizatio…
36 O.S. § 6570.7 Services not requiring prior authorization — Time frame
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to notify utilization review entity of such services. A. A utilization review entity shall not require prior authorization for pre-hospital transportation, for the provision of emergency health care services, or for transfers between facilities as required by the Emergency Medica…
36 O.S. § 6570.8 Time frame in which prior authorization may not be
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altered — Contracted payment rate requirement and exceptions. A. A health benefit plan may not revoke, limit, condition, or restrict a prior authorization if care is provided within forty-five (45) business days from the date the health care provider received the prior authorizat…