Okla. Stat. tit. 56, § 56-4002.6: Requirements for prior authorizations

A. A contracted entity shall meet all requirements established

by this section pertaining to prior authorizations.

To the extent a contracted entity uses a third-party utilization

review entity to administer prior authorizations on its behalf, the

utilization review entity shall comply with the provisions of this

section applicable to contracted entities.

B. 1. A contracted entity shall make any current prior

authorization requirements and restrictions, including written

clinical criteria, readily accessible on its website to members and

participating providers. Such requirements and restrictions shall

be described in detail but also in easily understandable language.

2. If a contracted entity intends either to implement a new

prior authorization requirement or restriction or to amend an

existing requirement or restriction, the contracted entity shall:

a. ensure that the new or amended requirement or

restriction is not implemented until the contracted

entity’s website has been updated to reflect the new

or amended requirement or restriction, and

b. provide participating providers credentialed to

perform the service, and members who have a chronic

condition and are already receiving the service which

the prior authorization changes will impact, notice of

the new or amended requirement or restriction no less

than sixty (60) days before the requirement or

restriction is implemented.

C. A contracted entity shall ensure that all adverse

determinations are made by a licensed physician or, if appropriate

for the requested service, a licensed mental health professional.

The physician or mental health professional shall:

1. Possess a current and valid nonrestricted license in any

United States jurisdiction;

2. Have the appropriate training, knowledge, or expertise to

apply appropriate clinical guidelines to the health care service

being requested; and

3. Make the adverse determination under the clinical direction

of a medical director of the contracted entity who is responsible

for reviewing health care services to members. Any such medical

director shall be a physician licensed in any United States

jurisdiction.

D. 1. Not later than January 1, 2027, each contracted entity

shall implement and maintain a Prior Authorization Application

Programming Interface (API), as described in 45 C.F.R., Part 156.

2. Not later than July 1, 2027, all participating providers

shall have electronic health records or practice management systems

that are compatible with the API, subject to such exceptions as may

be authorized by the Oklahoma Health Care Authority Board through

rule.

E. 1. If a contracted entity or the Authority requires prior

authorization of a health care service, the contracted entity shall

make a prior authorization or adverse determination in accordance

with the following time periods:

a. for urgent health care services, within seventy-two

(72) hours of obtaining all necessary information to

make the prior authorization or adverse determination,

b. for non-urgent health care services, within seven (7)

days of obtaining all necessary information to make

the prior authorization or adverse determination,

c. for covered prescription drugs, within twenty-four

, within seventy-two

(72) hours of obtaining all necessary information to

make the prior authorization or adverse determination,

b. for non-urgent health care services, within seven (7)

days of obtaining all necessary information to make

the prior authorization or adverse determination,

c. for covered prescription drugs, within twenty-four

(24) hours of obtaining all necessary information to

make the prior authorization or adverse determination.

The contracted entity shall not require prior

authorization on any covered prescription drug for

which the Authority does not require prior

authorization, and

d. for coverage of biomarker testing, in accordance with

Section 4003 of this title.

2. If a participating provider submits all necessary

information through the contracted entity’s authorized prior

authorization system, and if the contracted entity fails to comply

with the deadlines specified in this subsection, such health care

services are deemed authorized.

3. For the purposes of this subsection, “necessary information”

includes, but is not limited to, the results of any face-to-face

clinical evaluation or second opinion that may be required.

F. 1. If a member needs emergency health care services, the

member’s contracted 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 federal Emergency Medical Treatment and Labor Act.

2. A contracted entity shall allow a member and the member’s

provider a minimum of twenty-four (24) hours following an emergency

admission or provision of emergency health care services for the

member or provider to notify the contracted entity of the admission

or provision of health care services. If the admission or health

care service occurs on a holiday or weekend, the contracted entity

shall not require notification until the next business day after the

admission or provision of the health care services.

G. 1. In the notification to the provider that a prior

authorization has been approved, the contracted entity shall include

in such notification the duration of the prior authorization or the

date by which the prior authorization will expire.

2. A contracted entity shall not revoke, limit, condition, or

restrict a prior authorization if the authorized service is provided

within forty-five (45) business days from the date the provider

received the prior authorization unless the member was no longer

eligible for the service on the date it was provided.

3. On receipt of information documenting a prior authorization

from the member or from the member’s provider, a contracted entity

shall honor a prior authorization granted to a member from a

previous contracted entity for at least the initial sixty (60) days

of a member’s coverage under a new contracted entity. During the

time period described in this subsection, a contracted entity may

perform its own review to grant a prior authorization or make an

adverse determination.

H. A contracted entity shall provide participating providers

with the following opportunities for communication during the prior

authorization process:

1. Make staff available at least eight (8) hours each day

during normal business hours for inbound telephone calls regarding

prior authorization issues;

2. Allow staff to receive inbound communication regarding prior

authorization issues after normal business hours; and

3. Provide a participating provider with the opportunity to

discuss a prior authorization denial with an appropriate reviewer.

I. A contracted entity shall reimburse a participating provider

at the contracted payment rate for a health care service provided by

the provider per a prior authorization, subject to any applicable

egarding prior

authorization issues after normal business hours; and

3. Provide a participating provider with the opportunity to

discuss a prior authorization denial with an appropriate reviewer.

I. A contracted entity shall reimburse a participating provider

at the contracted payment rate for a health care service provided by

the provider per a prior authorization, subject to any applicable

reimbursement requirements provided by Section 4002.12 of this

title, unless:

1. The provider knowingly and materially misrepresented the

health care service in the prior authorization request with the

specific intent to deceive and obtain an unlawful payment from a

contracted entity;

2. The health care service was no longer a covered benefit on

the day it was provided;

3. The provider was no longer contracted with the member’s

contracted entity on the date the service was provided;

4. The provider failed to meet the contracted entity’s timely

filing requirements; or

5. The member was no longer eligible for health care coverage

on the date the service was provided.