{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6055","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6055","heading":"Performance of services and procedures by practitioners -","body":"Freedom of choice - Exclusions - Compensation of practitioners -\n\nDecisions to authorize or deny emergency services.\n\nA. Under any accident and health insurance policy, hereafter\n\nrenewed or issued for delivery from out of Oklahoma or in Oklahoma\n\nby any insurer and covering an Oklahoma risk, the services and\n\nprocedures may be performed by any practitioner selected by the\n\ninsured, or the parent or guardian of the insured if the insured is\n\na minor, if the services and procedures fall within the licensed\n\nscope of practice of the practitioner providing the same.\n\nB. An accident and health insurance policy may:\n\n1. Exclude or limit coverage for a particular illness, disease,\n\ninjury or condition; but, except for such exclusions or limits,\n\nshall not exclude or limit particular services or procedures that\n\ncan be provided for the diagnosis and treatment of a covered\n\nillness, disease, injury or condition, if such exclusion or\n\nlimitation has the effect of discriminating against a particular\n\nclass of practitioner. However, such services and procedures, in\n\norder to be a covered medical expense, must:\n\na. be medically necessary,\n\nb. be of proven efficacy, and\n\nc. fall within the licensed scope of practice of the\n\npractitioner providing same; and\n\n2. Provide for the application of deductibles and copayment\n\nprovisions, when equally applied to all covered charges for services\n\nand procedures that can be provided by any practitioner for the\n\ndiagnosis and treatment of a covered illness, disease, injury or\n\ncondition.\n\nC. 1. Paragraph 2 of subsection B of this section shall not be\n\nconstrued to prohibit differences in cost-sharing provisions such as\n\ndeductibles and copayment provisions between practitioners,\n\nhospitals, ambulatory surgical centers, home care agencies, or other\n\nhealth care providers or facilities that are licensed or certified\n\nby the state who are participating preferred provider organization\n\nproviders and practitioners, hospitals, ambulatory surgical centers,\n\nhome care agencies, or other health care providers or facilities\n\nthat are licensed or certified by the state who are not\n\nparticipating in the preferred provider organization, subject to the\n\nfollowing limitations:\n\na. the amount of any annual deductible per covered person\n\nor per family for treatment in a hospital or\n\nambulatory surgical center that is not a preferred\n\nprovider shall not exceed three times the amount of a\n\ncorresponding annual deductible for treatment in a\n\nhospital or ambulatory surgical center that is a\n\npreferred provider,\n\nb. if the policy has no deductible for treatment in a\n\npreferred provider hospital or ambulatory surgical\n\ncenter, the deductible for treatment in a hospital or\n\nambulatory surgical center that is not a preferred\n\nprovider shall not exceed One Thousand Dollars\n\n($1,000.00) per covered-person visit,\n\nc. the amount of any annual deductible per covered person\n\nor per family treatment, other than inpatient\n\ntreatment, by a practitioner that is not a preferred\n\npractitioner shall not exceed three times the amount\n\nof a corresponding annual deductible for treatment,\n\nother than inpatient treatment, by a preferred\n\npractitioner,\n\nd. if the policy has no deductible for treatment by a\n\npreferred practitioner, the annual deductible for\n\ntreatment received from a practitioner that is not a\n\npreferred practitioner shall not exceed Five Hundred\n\nDollars ($500.00) per covered person, and\n\ne. the percentage amount of any coinsurance to be paid by\n\nan insured to a practitioner, hospital or ambulatory\n\nsurgical center that is not a preferred provider shall\n\nnot exceed by more than thirty (30) percentage points\n\nthe percentage amount of any coinsurance payment to be\n\npaid to a preferred provider.\n\n2. The Commissioner has discretion to approve a cost-sharing\n\narrangement which does not satisfy the limitations imposed by this\nance to be paid by\n\nan insured to a practitioner, hospital or ambulatory\n\nsurgical center that is not a preferred provider shall\n\nnot exceed by more than thirty (30) percentage points\n\nthe percentage amount of any coinsurance payment to be\n\npaid to a preferred provider.\n\n2. The Commissioner has discretion to approve a cost-sharing\n\narrangement which does not satisfy the limitations imposed by this\n\nsubsection if the Commissioner finds that such cost-sharing\n\narrangement will provide a reduction in premium costs.\n\nD. 1. A practitioner, hospital, ambulatory surgical center,\n\nhome care agency, or other health care provider or facility that is\n\nlicensed or certified by the state that is not a preferred provider\n\nshall disclose to the insured, in writing, that the insured may be\n\nresponsible for:\n\na. higher coinsurance and deductibles, and\n\nb. practitioner, hospital or ambulatory surgical center\n\ncharges which exceed the allowable charges of a\n\npreferred provider, and\n\nc. a good-faith estimate of the total cost to the\n\ninsured.\n\n2. When a referral is made to a nonparticipating hospital or\n\nambulatory surgical center, the referring practitioner must disclose\n\nin writing to the insured, any ownership interest in the\n\nnonparticipating hospital or ambulatory surgical center.\n\nE. Upon submission of a claim by a practitioner, hospital, home\n\ncare agency, ambulatory surgical center, or other health care\n\nprovider or facility that is licensed or certified by the state to\n\nan insurer on a uniform health care claim form adopted by the\n\nInsurance Commissioner pursuant to Section 6581 of this title, the\n\ninsurer shall provide a timely explanation of benefits to the\n\npractitioner, hospital, home care agency, ambulatory surgical\n\ncenter, or other health care provider or facility that is licensed\n\nor certified by the state regardless of the network participation\n\nstatus of such person or entity.\n\nF. Benefits available under an accident and health insurance\n\npolicy, at the option of the insured, shall be assignable to a\n\npractitioner, hospital, home care agency, ambulatory surgical\n\ncenter, or other health care provider or facility that is licensed\n\nor certified by the state who has provided services and procedures\n\nwhich are covered under the policy. A practitioner, hospital, home\n\ncare agency, ambulatory surgical center, or other health care\n\nprovider or facility that is licensed or certified by the state\n\nshall be compensated directly by an insurer for services and\n\nprocedures which have been provided when the following conditions\n\nare met:\n\n1. Benefits available under a policy have been assigned in\n\nwriting by an insured to the practitioner, hospital, home care\n\nagency, ambulatory surgical center, or other health care provider or\n\nfacility that is licensed or certified by the state;\n\n2. A copy of the assignment has been provided by the\n\npractitioner, hospital, home care agency, ambulatory surgical\n\ncenter, or other health care provider or facility that is licensed\n\nor certified by the state to the insurer;\n\n3. A claim has been submitted by the practitioner, hospital,\n\nhome care agency, ambulatory surgical center, or other health care\n\nprovider or facility that is licensed or certified by the state to\n\nthe insurer on a uniform health insurance claim form adopted by the\n\nInsurance Commissioner pursuant to Section 6581 of this title; and\n\n4. A copy of the claim and the estimate required in\n\nsubparagraph c of paragraph 1 of subsection D of this section have\n\nbeen provided by the practitioner, hospital, home care agency,\n\nambulatory surgical center, or other health care provider or\n\nfacility that is licensed or certified by the state to the insured.\n\nG. The provisions of subsection F of this section shall not\n\napply to:\n\n1. Any preferred provider organization (PPO), as defined by\n\ngenerally accepted industry standards, that contracts with\nspital, home care agency,\n\nambulatory surgical center, or other health care provider or\n\nfacility that is licensed or certified by the state to the insured.\n\nG. The provisions of subsection F of this section shall not\n\napply to:\n\n1. Any preferred provider organization (PPO), as defined by\n\ngenerally accepted industry standards, that contracts with\n\npractitioners that agree to accept the reimbursement available under\n\nthe PPO agreement as payment in full and agree not to balance bill\n\nthe insured; or\n\n2. Any statewide provider network which:\n\na. provides that a practitioner, hospital, home care\n\nagency, ambulatory surgical center, or other health\n\ncare provider or facility that is licensed or\n\ncertified by the state who joins the provider network\n\nshall be compensated directly by the insurer,\n\nb. does not have any terms or conditions which have the\n\neffect of discriminating against a particular class of\n\npractitioner,\n\nc. allows any practitioner, hospital, home care agency,\n\nambulatory surgical center, or other health care\n\nprovider or facility that is licensed or certified by\n\nthe state, except a practitioner who has a prior\n\nfelony conviction, to become a network provider if the\n\nhospital or practitioner is willing to comply with the\n\nterms and conditions of a standard network provider\n\ncontract, and\n\nd. contracts with practitioners that agree to accept the\n\nreimbursement available under the network agreement as\n\npayment in full and agree not to balance bill the\n\ninsured.\n\nThe provisions of this section shall not be deemed to prohibit a\n\npolicyholder from assigning benefits available pursuant to an\n\naccident and health insurance policy, provided that the benefits of\n\nsuch policy include out-of-network provisions and are being assigned\n\nto an out-of-network practitioner, hospital, home care agency,\n\nambulatory surgical center, or other health care provider or\n\nfacility that is licensed or certified by the state. The\n\nassignability of an accident and health insurance policy related to\n\nout-of-network care shall only be subject to the terms and\n\nconditions specified in subsection F of this section.\n\nH. A nonparticipating practitioner, hospital or ambulatory\n\nsurgical center may request from an insurer and the insurer shall\n\nsupply a good-faith estimate of the allowable fee for a procedure to\n\nbe performed upon an insured based upon information regarding the\n\nanticipated medical needs of the insured provided to the insurer by\n\nthe nonparticipating practitioner.\n\nI. A practitioner shall be equally compensated for covered\n\nservices and procedures provided to an insured on the basis of\n\ncharges prevailing in the same geographical area or in similar sized\n\ncommunities for similar services and procedures provided to\n\nsimilarly ill or injured persons regardless of the branch of the\n\nhealing arts to which the practitioner may belong, if:\n\n1. The practitioner does not authorize or permit false and\n\nfraudulent advertising regarding the services and procedures\n\nprovided by the practitioner; and\n\n2. The practitioner does not aid or abet the insured to violate\n\nthe terms of the policy.\n\nJ. Nothing in the Health Care Freedom of Choice Act shall\n\nprohibit an insurer from establishing a preferred provider\n\norganization and a standard participating provider contract\n\ntherefor, specifying the terms and conditions, including, but not\n\nlimited to, provider qualifications, and alternative levels or\n\nmethods of payment that must be met by a practitioner selected by\n\nthe insurer as a participating preferred provider organization\n\nprovider.\n\nK. A preferred provider organization, in executing a contract,\n\nshall not, by the terms and conditions of the contract or internal\n\nprotocol, discriminate within its network of practitioners with\n\nrespect to participation and reimbursement as it relates to any\nthods of payment that must be met by a practitioner selected by\n\nthe insurer as a participating preferred provider organization\n\nprovider.\n\nK. A preferred provider organization, in executing a contract,\n\nshall not, by the terms and conditions of the contract or internal\n\nprotocol, discriminate within its network of practitioners with\n\nrespect to participation and reimbursement as it relates to any\n\npractitioner who is acting within the scope of the practitioner's\n\nlicense under the law solely on the basis of such license.\n\nL. Decisions by an insurer or a preferred provider organization\n\n(PPO) to authorize or deny coverage for an emergency service shall\n\nbe based on the patient presenting symptoms arising from any injury,\n\nillness, or condition manifesting itself by acute symptoms of\n\nsufficient severity, including severe pain, such that a reasonable\n\nand prudent layperson could expect the absence of medical attention\n\nto result in serious:\n\n1. Jeopardy to the health of the patient;\n\n2. Impairment of bodily function; or\n\n3. Dysfunction of any bodily organ or part.\n\nM. An insurer or preferred provider organization (PPO) shall\n\nnot deny an otherwise covered emergency service based solely upon\n\nlack of notification to the insurer or PPO.\n\nN. An insurer or a preferred provider organization (PPO) shall\n\ncompensate a provider for patient screening, evaluation, and\n\nexamination services that are reasonably calculated to assist the\n\nprovider in determining whether the condition of the patient\n\nrequires emergency service. If the provider determines that the\n\npatient does not require emergency service, coverage for services\n\nrendered subsequent to that determination shall be governed by the\n\npolicy or PPO contract.\n\nO. Nothing in the Health Care Freedom of Choice Act shall be\n\nconstrued as prohibiting an insurer, preferred provider organization\n\nor other network from determining the adequacy of the size of its\n\nnetwork.\n\nP. An insurer or a preferred provider organization shall not\n\nunilaterally remove a provider from the network solely because the\n\nprovider informs an enrollee of the full range of physicians and\n\nproviders available to the enrollee including out-of-network\n\nproviders. Nothing in the Health Care Freedom of Choice Act\n\nprohibits any insurer from allowing a contract to expire by its own\n\nterms or negotiating a new contract with the provider at the end of\n\nthe contract term. A provider agreement shall not, as a condition\n\nof the agreement, prohibit, penalize, terminate, or otherwise\n\nrestrict a preferred provider from referring to an out-of-network\n\nprovider; provided, the insured signs an acknowledgment of referral\n\nthat the insured may be responsible for:\n\n1. Higher coinsurance and deductibles; and\n\n2. Charges which exceed the allowable charges of a preferred\n\nprovider.","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":"6389b09b98cc22eebc7f11733f00afbb559fdc31ae793e64ea2683770649d716","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6054","next":"us-ok/okla.-stat.-tit.-36-36-6056"},"notice":"GroundRules: Original legal text. Not legal advice."}