{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-4405.1","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-4405.1","heading":"Health benefit plans - Credentialing or recredentialing","body":"of physicians and other health care providers.\n\nA. As used in this section:\n\n1. a. “Health benefit plan” or “plan” means:\n\n(1) group hospital or medical insurance coverages,\n\n(2) not-for-profit hospital or medical service or\n\nindemnity plans,\n\n(3) prepaid health plans,\n\n(4) health maintenance organizations,\n\n(5) preferred provider plans,\n\n(6) multiple employer welfare arrangements (MEWA), or\n\n(7) employer self-insured plans that are not exempt\n\npursuant to the federal Employee Retirement\n\nIncome Security Act of 1974 (ERISA) provisions,\n\nand\n\nb. the term health benefit plan shall not include:\n\n(1) individual plans,\n\n(2) plans that only provide coverage for a specified\n\ndisease, accidental death, or dismemberment for\n\nwages or payments in lieu of wages for a period\n\nduring which an employee is absent from work\n\nbecause of sickness or injury or as a supplement\n\nto liability insurance,\n\n(3) Medicare supplemental policies as defined in\n\nSection 1882(g)(1) of the federal Social Security\n\nAct (42 U.S.C., Section 1395ss),\n\n(4) workers’ compensation insurance coverage,\n\n(5) medical payment insurance issued as a part of a\n\nmotor vehicle insurance policy, or\n\n(6) long-term care policies, including nursing home\n\nfixed indemnity policies, unless the Insurance\n\nCommissioner determines that the policy provides\n\ncomprehensive benefit coverage sufficient to meet\n\nthe definition of a health benefit plan; and\n\n2. “Credentialing” or “recredentialing”, as applied to\n\nphysicians and other health care providers, means the process of\n\naccessing and validating the qualifications of such persons to\n\nprovide health care services to the beneficiaries of a health\n\nbenefit plan. Credentialing or recredentialing may include, but is\n\nnot limited to, an evaluation of licensure status, education,\n\ntraining, experience, competence and professional judgment.\n\nCredentialing or recredentialing is a prerequisite to the final\n\ndecision of a health benefit plan to permit initial or continued\n\nparticipation by a physician or other health care provider.\n\nB. 1. Any health benefit plan that is offered, issued or\n\nrenewed in this state shall provide for credentialing and\n\nrecredentialing of physicians and other health care providers based\n\non criteria provided in the uniform credentialing application\n\nrequired by Section 1-106.2 of Title 63 of the Oklahoma Statutes.\n\n2. Health benefit plans shall make information on such criteria\n\navailable to physician and other health care provider applicants,\n\nparticipating physicians, and other participating health care\n\nproviders and shall provide applicants with a checklist of materials\n\nrequired in the application process.\n\n3. Physicians or other health care providers under\n\nconsideration to provide health care services under a health benefit\n\nplan in this state shall apply for credentialing or recredentialing\n\non the uniform credentialing application and shall provide the\n\ndocumentation as outlined in the plan’s checklist of materials\n\nrequired in the application process.\n\nC. A health benefit plan shall determine whether a\n\ncredentialing or recredentialing application is complete. If an\n\napplication is determined to be incomplete, the plan shall notify\n\nthe applicant in writing within ten (10) calendar days of receipt of\n\nthe application. The written notice shall specify the portion of\n\nthe application that is causing a delay in processing and explain\n\nany additional information or corrections needed.\n\nD. 1. In reviewing the application, the health benefit plan\n\nshall evaluate each application according to the plan’s checklist of\n\nrequired materials that accompanies the application.\n\n2. When an application is deemed complete, the plan shall\n\ninitiate requests for primary source verification and malpractice\n\nhistory within seven (7) calendar days.\n\n3. A malpractice carrier shall have twenty-one (21) calendar\n\ndays within which to respond after receipt of an inquiry from a\nach application according to the plan’s checklist of\n\nrequired materials that accompanies the application.\n\n2. When an application is deemed complete, the plan shall\n\ninitiate requests for primary source verification and malpractice\n\nhistory within seven (7) calendar days.\n\n3. A malpractice carrier shall have twenty-one (21) calendar\n\ndays within which to respond after receipt of an inquiry from a\n\nhealth benefit plan. Any malpractice carrier that fails to respond\n\nto an inquiry within the time frame may be assessed an\n\nadministrative penalty by the Insurance Commissioner.\n\nE. 1. Upon receipt of primary source verification and\n\nmalpractice history by the plan, the plan shall determine if the\n\napplication is a clean application. If the application is deemed\n\nclean, a plan shall have forty-five (45) calendar days within which\n\nto credential or recredential a physician or other health care\n\nprovider. As used in this paragraph, “clean application” means an\n\napplication that has no defect, misstatement of facts,\n\nimproprieties, including a lack of any required substantiating\n\ndocumentation, or particular circumstance requiring special\n\ntreatment that impedes prompt credentialing or recredentialing.\n\n2. If a plan is unable to credential or recredential a\n\nphysician or other health care provider due to an application not\n\nbeing clean, the plan may extend the credentialing or\n\nrecredentialing process for sixty (60) calendar days. At the end of\n\nsixty (60) calendar days, if the plan is awaiting documentation to\n\ncomplete the application, the physician or other health care\n\nprovider shall be notified of the reason for the delay by certified\n\nmail. The physician or other health care provider may extend the\n\nsixty-day period upon written notice to the plan within ten (10)\n\ncalendar days; otherwise the application shall be deemed withdrawn.\n\nIn no event shall the entire credentialing or recredentialing\n\nprocess exceed one hundred eighty (180) calendar days.\n\n3. If an application for credentialing or recredentialing is\n\ndenied, the plan shall notify the applicant in writing the reason\n\nfor the denial and what corrective actions the applicant may\n\nconsider within ten (10) calendar days of the determination to deny\n\nthe application.\n\n4. A health benefit plan shall be prohibited from solely basing\n\na denial of an application for credentialing or recredentialing on\n\nthe lack of board certification or board eligibility and from adding\n\nnew requirements solely for the purpose of delaying an application.\n\n5. Any health benefit plan that violates the provisions of this\n\nsection may be assessed an administrative penalty by the\n\nCommissioner.\n\nF. Within thirty-one (31) days after a provider has been\n\ncredentialed by a health benefit plan following the completion of\n\nthe credentialing or recredentialing process pursuant to this\n\nsection, the health benefit plan shall consider the provider in-\n\nnetwork for purposes of reimbursement.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"1e2a94da924f9726815306023b6eafe6a0c5672a633dae80b06e192674cbb8c6","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-4405","next":"us-ok/okla.-stat.-tit.-36-36-4406"},"notice":"GroundRules: Original legal text. Not legal advice."}