Okla. Stat. tit. 63, § 63-2550.2: Referral to and treatment by specialist

A. A managed care plan that has no participating provider for a

covered benefit requiring a specialist shall arrange for a referral

to a specialist with expertise in treating the covered benefit. The

specialist shall agree to abide by the terms of the plan’s provider

contract if the terms are commensurate with the terms of contracts

for similar specialists.

B. 1. A managed care plan shall include procedures by which a

covered person in a managed care plan, upon diagnosis by a primary

care provider of a condition that without specialized treatment

would result in deleterious outcomes that would threaten life or

limb or a degenerative and disabling condition or disease, either of

which requires specialized medical care over a prolonged period of

time, may be referred to a specialist with expertise in treating

such condition or disease.

2. The specialist may be responsible for and may provide and

coordinate the covered person’s primary and specialty care only if

the specialist is willing to abide by the terms of the plan’s

contract and capable of providing such care.

3. If the managed care plan, or the primary care provider in

consultation with the managed care plan and the specialist, if any,

determines that the most appropriate coordinator of the covered

person’s care is a specialist, the managed care plan shall authorize

a referral of the covered person to the specialist. In no event

shall a managed care plan be required to permit a covered person to

elect treatment by a nonparticipating specialist, except pursuant to

the provisions of subsection A of this section.

C. 1. A referral pursuant to this section shall be pursuant to

a treatment plan agreed to by the managed care plan, the specialist

and the primary care provider which complies with the covered

benefits of the health plan and which is developed in consultation

with the primary care provider, if appropriate, the specialist, and

the covered person or the designee of the covered person.

2. Subject to the terms of the treatment plan agreed to by the

managed care plan, the specialist and the primary care provider and

subject to the terms of the plan’s contract, a specialist shall be

permitted to treat the covered person without a referral from the

covered person’s primary care provider and may authorize referrals,

procedures, tests and other medical services as the covered person’s

primary care provider would otherwise be permitted to provide or

authorize.

3. If a managed care plan refers a covered person to a

nonparticipating specialist, services provided pursuant to the

treatment plan shall be provided pursuant to the provisions of

subsection A of this section at no additional cost to the covered

person beyond what the covered person would otherwise pay for

services received within the network of the managed care plan.

D. A managed care plan shall implement procedures for a

standing referral to a specialist if the primary care provider

determines in consultation with the specialist and the managed care

plan that a covered person needs continuing care from a specialist.

The referral shall be made pursuant to a treatment plan that

complies with covered benefits of the managed care plan.