{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.10","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.10","heading":"Timeframe for filing request for external review","body":"A. 1. Within four (4) months after the date of receipt of a\n\nnotice of an adverse determination or final adverse determination\n\npursuant to Section 6475.5 of this title that involves a denial of\n\ncoverage based on a determination that the health care service or\n\ntreatment recommended or requested is experimental or\n\ninvestigational, a covered person or the covered person's authorized\n\nrepresentative may file a request for external review with the\n\nInsurance Commissioner.\n\n2. a. A covered person or the covered person's authorized\n\nrepresentative may make an oral request for an\n\nexpedited external review of the adverse determination\n\nor final adverse determination pursuant to paragraph 1\n\nof this subsection if the covered person's treating\n\nphysician certifies, in writing, that the recommended\n\nor requested health care service or treatment that is\n\nthe subject of the request would be significantly less\n\neffective if not promptly initiated.\n\nb. Upon receipt of a request for an expedited external\n\nreview, the Commissioner immediately shall notify the\n\nhealth carrier.\n\nc. (1) Upon notice of the request for expedited external\n\nreview, the health carrier immediately shall\n\ndetermine whether the request meets the\n\nreviewability requirements of subsection B of\n\nthis section. The health carrier shall\n\nimmediately notify the Commissioner and the\n\ncovered person and, if applicable, the covered\n\nperson's authorized representative of its\n\neligibility determination.\n\n(2) The Commissioner may specify the form for the\n\nhealth carrier's notice of initial determination\n\nunder division (1) of this subparagraph and any\n\nsupporting information to be included in the\n\nnotice.\n\n(3) The notice of initial determination under\n\ndivision (1) of this subparagraph shall include a\n\nstatement informing the covered person and, if\n\napplicable, the covered person's authorized\n\nrepresentative that a health carrier's initial\n\ndetermination that the external review request is\n\nineligible for review may be appealed to the\n\nCommissioner.\n\nd. (1) The Commissioner may determine that a request is\n\neligible for external review under paragraph 2 of\n\nsubsection B of this section notwithstanding a\n\nhealth carrier's initial determination the\n\nrequest is ineligible and require that it be\n\nreferred for external review.\n\n(2) In making a determination under division (1) of\n\nthis subparagraph, the Commissioner's decision\n\nshall be made in accordance with the terms of the\n\ncovered person's health benefit plan and shall be\n\nsubject to all applicable provisions of the\n\nUniform Health Carrier External Review Act.\n\ne. Upon receipt of the notice that the expedited external\n\nreview request meets the reviewability requirements of\n\nparagraph 2 of subsection B of this section, the\n\nCommissioner immediately shall assign an independent\n\nreview organization to review the expedited request\n\nfrom the list of approved independent review\n\norganizations compiled and maintained by the\n\nCommissioner pursuant to Section 6475.12 of this title\n\nand notify the health carrier of the name of the\n\nassigned independent review organization.\n\nf. At the time the health carrier receives the notice of\n\nthe assigned independent review organization pursuant\n\nto subparagraph e of this paragraph, the health\n\ncarrier or its designee utilization review\n\norganization shall provide or transmit all necessary\n\ndocuments and information considered in making the\n\nadverse determination or final adverse determination\n\nto the assigned independent review organization\n\nelectronically or by telephone or facsimile or any\n\nother available expeditious method.\n\nB. 1. Except for a request for an expedited external review\n\nmade pursuant to paragraph 2 of subsection A of this section, within\n\none (1) business day after the date of receipt of the request, the\n\nCommissioner receives a request for an external review, the\n\nCommissioner shall notify the health carrier.\ntion\n\nelectronically or by telephone or facsimile or any\n\nother available expeditious method.\n\nB. 1. Except for a request for an expedited external review\n\nmade pursuant to paragraph 2 of subsection A of this section, within\n\none (1) business day after the date of receipt of the request, the\n\nCommissioner receives a request for an external review, the\n\nCommissioner shall notify the health carrier.\n\n2. Within five (5) business days following the date of receipt\n\nof the notice sent pursuant to paragraph 1 of this subsection, the\n\nhealth carrier shall conduct and complete a preliminary review of\n\nthe request to determine whether:\n\na. the individual is or was a covered person in the\n\nhealth benefit plan at the time the health care\n\nservice or treatment was recommended or requested or,\n\nin the case of a retrospective review, was a covered\n\nperson in the health benefit plan at the time the\n\nhealth care service or treatment was provided,\n\nb. the recommended or requested health care service or\n\ntreatment that is the subject of the adverse\n\ndetermination or final adverse determination:\n\n(1) is a covered benefit under the covered person's\n\nhealth benefit plan except for the health\n\ncarrier's determination that the service or\n\ntreatment is experimental or investigational for\n\na particular medical condition, and\n\n(2) is not explicitly listed as an excluded benefit\n\nunder the covered person's health benefit plan\n\nwith the health carrier,\n\nc. the covered person's treating physician has certified\n\nthat one of the following situations is applicable:\n\n(1) standard health care services or treatments have\n\nnot been effective in improving the condition of\n\nthe covered person,\n\n(2) standard health care services or treatments are\n\nnot medically appropriate for the covered person,\n\nor\n\n(3) there is no available standard health care\n\nservice or treatment covered by the health\n\ncarrier that is more beneficial than the\n\nrecommended or requested health care service or\n\ntreatment described in subparagraph d of this\n\nparagraph,\n\nd. the covered person's treating physician:\n\n(1) has recommended a health care service or\n\ntreatment that the physician certifies, in\n\nwriting, is likely to be more beneficial to the\n\ncovered person, in the physician's opinion, than\n\nany available standard health care services or\n\ntreatments, or\n\n(2) who is a licensed, board-certified or board-\n\neligible physician qualified to practice in the\n\narea of medicine appropriate to treat the covered\n\nperson's condition, has certified in writing that\n\nscientifically valid studies using accepted\n\nprotocols demonstrate that the health care\n\nservice or treatment requested by the covered\n\nperson that is the subject of the adverse\n\ndetermination or final adverse determination is\n\nlikely to be more beneficial to the covered\n\nperson than any available standard health care\n\nservices or treatments,\n\ne. the covered person has exhausted the health carrier's\n\ninternal grievance process unless the covered person\n\nis not required to exhaust the health carrier's\n\ninternal grievance process pursuant to Section 6475.7\n\nof this title, and\n\nf. the covered person has provided all the information\n\nand forms required by the Commissioner that are\n\nnecessary to process an external review including the\n\nrelease form provided under subsection B of Section\n\n6475.5 of this title.\n\nC. 1. Within one (1) business day after completion of the\n\npreliminary review, the health carrier shall notify the Commissioner\n\nand the covered person and, if applicable, the covered person's\n\nauthorized representative in writing whether:\n\na. the request is complete, and\n\nb. the request is eligible for external review.\n\n2. If the request:\n\na. is not complete, the health carrier shall inform in\n\nwriting the Commissioner and the covered person and,\n\nif applicable, the covered person's authorized\nhall notify the Commissioner\n\nand the covered person and, if applicable, the covered person's\n\nauthorized representative in writing whether:\n\na. the request is complete, and\n\nb. the request is eligible for external review.\n\n2. If the request:\n\na. is not complete, the health carrier shall inform in\n\nwriting the Commissioner and the covered person and,\n\nif applicable, the covered person's authorized\n\nrepresentative and include in the notice what\n\ninformation or materials are needed to make the\n\nrequest complete, or\n\nb. is not eligible for external review, the health\n\ncarrier shall inform the covered person, the covered\n\nperson's authorized representative, if applicable, and\n\nthe Commissioner in writing and include in the notice\n\nthe reasons for its ineligibility.\n\n3. a. The Commissioner may specify the form for the health\n\ncarrier's notice of initial determination under\n\nparagraph 2 of this subsection and any supporting\n\ninformation to be included in the notice.\n\nb. The notice of initial determination provided under\n\nparagraph 2 of this subsection shall include a\n\nstatement informing the covered person and, if\n\napplicable, the covered person's authorized\n\nrepresentative that a health carrier's initial\n\ndetermination that the external review request is\n\nineligible for review may be appealed to the\n\nCommissioner.\n\n4. a. The Commissioner may determine that a request is\n\neligible for external review under paragraph 2 of\n\nsubsection B of this section notwithstanding a health\n\ncarrier's initial determination that the request is\n\nineligible and require that it be referred for\n\nexternal review.\n\nb. In making a determination under subparagraph a of this\n\nparagraph, the Commissioner's decision shall be made\n\nin accordance with the terms of the covered person's\n\nhealth benefit plan and shall be subject to all\n\napplicable provisions of the Uniform Health Carrier\n\nExternal Review Act.\n\n5. Whenever a request for external review is determined\n\neligible for external review, the health carrier shall notify the\n\nCommissioner and the covered person and, if applicable, the covered\n\nperson's authorized representative.\n\nD. 1. Within one (1) business day after the receipt of the\n\nnotice from the health carrier that the external review request is\n\neligible for external review pursuant to subparagraph d of paragraph\n\n2 of subsection A of this section or paragraph 5 of subsection C of\n\nthis section, the Commissioner shall:\n\na. assign an independent review organization to conduct\n\nthe external review from the list of approved\n\nindependent review organizations compiled and\n\nmaintained by the Commissioner pursuant to Section\n\n6475.12 of this title and notify the health carrier of\n\nthe name of the assigned independent review\n\norganization, and\n\nb. notify in writing the covered person and, if\n\napplicable, the covered person's authorized\n\nrepresentative of the request's eligibility and\n\nacceptance for external review.\n\n2. The Commissioner shall include in the notice provided to the\n\ncovered person and, if applicable, the covered person's authorized\n\nrepresentative a statement that the covered person or the covered\n\nperson's authorized representative may submit in writing to the\n\nassigned independent review organization within five (5) business\n\ndays following the date of receipt of the notice provided pursuant\n\nto paragraph 1 of this subsection, additional information that the\n\nindependent review organization shall consider when conducting the\n\nexternal review. The independent review organization is not\n\nrequired to, but may, accept and consider additional information\n\nsubmitted after five (5) business days.\n\n3. Within one (1) business day after the receipt of the notice\n\nof assignment to conduct the external review pursuant to paragraph 1\n\nof this subsection, the assigned independent review organization\n\nshall:\n\na. select one or more clinical reviewers, as it\ndependent review organization is not\n\nrequired to, but may, accept and consider additional information\n\nsubmitted after five (5) business days.\n\n3. Within one (1) business day after the receipt of the notice\n\nof assignment to conduct the external review pursuant to paragraph 1\n\nof this subsection, the assigned independent review organization\n\nshall:\n\na. select one or more clinical reviewers, as it\n\ndetermines is appropriate, pursuant to paragraph 4 of\n\nthis subsection to conduct the external review, and\n\nb. based on the opinion of the clinical reviewer, or\n\nopinions if more than one clinical reviewer has been\n\nselected to conduct the external review, make a\n\ndecision to uphold or reverse the adverse\n\ndetermination or final adverse determination.\n\n4. a. In selecting clinical reviewers pursuant to\n\nsubparagraph a of paragraph 3 of this subsection, the\n\nassigned independent review organization shall select\n\nphysicians or other health care professionals who meet\n\nthe minimum qualifications described in Section\n\n6475.13 of this title and, through clinical experience\n\nin the past three (3) years, are experts in the\n\ntreatment of the covered person's condition and\n\nknowledgeable about the recommended or requested\n\nhealth care service or treatment.\n\nb. Neither the covered person, the covered person's\n\nauthorized representative, if applicable, nor the\n\nhealth carrier, shall choose or control the choice of\n\nthe physicians or other health care professionals to\n\nbe selected to conduct the external review.\n\n5. In accordance with subsection H of this section, each\n\nclinical reviewer shall provide a written opinion to the assigned\n\nindependent review organization on whether the recommended or\n\nrequested health care service or treatment should be covered.\n\n6. In reaching an opinion, clinical reviewers are not bound by\n\nany decisions or conclusions reached during the health carrier's\n\nutilization review process as set forth in Sections 6551 through\n\n6565 of this title or the health carrier's internal grievance\n\nprocess.\n\nE. 1. Within five (5) business days after the date of receipt\n\nof the notice provided pursuant to paragraph 1 of subsection D of\n\nthis section, the health carrier or its designee utilization review\n\norganization shall provide to the assigned independent review\n\norganization the documents and any information considered in making\n\nthe adverse determination or the final adverse determination.\n\n2. Except as provided in paragraph 3 of this subsection,\n\nfailure by the health carrier or its designee utilization review\n\norganization to provide the documents and information within the\n\ntime specified in paragraph 1 of this subsection shall not delay the\n\nconduct of the external review.\n\n3. a. If the health carrier or its designee utilization\n\nreview organization has failed to provide the\n\ndocuments and information within the time specified in\n\nparagraph 1 of this subsection, the assigned\n\nindependent review organization may terminate the\n\nexternal review and make a decision to reverse the\n\nadverse determination or final adverse determination.\n\nb. Immediately upon making the decision under\n\nsubparagraph a of this paragraph, the independent\n\nreview organization shall notify the covered person,\n\nthe covered person's authorized representative, if\n\napplicable, the health carrier, and the Commissioner.\n\nF. 1. Each clinical reviewer selected pursuant to subsection D\n\nof this section shall review all of the information and documents\n\nreceived pursuant to subsection E of this section and any other\n\ninformation submitted in writing by the covered person or the\n\ncovered person's authorized representative pursuant to paragraph 2\n\nof subsection D of this section.\n\n2. Upon receipt of any information submitted by the covered\n\nperson or the covered person's authorized representative pursuant to\nursuant to subsection E of this section and any other\n\ninformation submitted in writing by the covered person or the\n\ncovered person's authorized representative pursuant to paragraph 2\n\nof subsection D of this section.\n\n2. Upon receipt of any information submitted by the covered\n\nperson or the covered person's authorized representative pursuant to\n\nparagraph 2 of subsection D of this section, within one (1) business\n\nday after the receipt of the information, the assigned independent\n\nreview organization shall forward the information to the health\n\ncarrier.\n\nG. 1. Upon receipt of the information required to be forwarded\n\npursuant to paragraph 2 of subsection F of this section, the health\n\ncarrier may reconsider its adverse determination or final adverse\n\ndetermination that is the subject of the external review.\n\n2. Reconsideration by the health carrier of its adverse\n\ndetermination or final adverse determination pursuant to paragraph 1\n\nof this subsection shall not delay or terminate the external review.\n\n3. The external review may be terminated only if the health\n\ncarrier decides, upon completion of its reconsideration, to reverse\n\nits adverse determination or final adverse determination and provide\n\ncoverage or payment for the recommended or requested health care\n\nservice or treatment that is the subject of the adverse\n\ndetermination or final adverse determination.\n\n4. a. Immediately upon making the decision to reverse its\n\nadverse determination or final adverse determination,\n\nas provided in paragraph 3 of this subsection, the\n\nhealth carrier shall notify the covered person, the\n\ncovered person's authorized representative if\n\napplicable, the assigned independent review\n\norganization, and the Commissioner in writing of its\n\ndecision.\n\nb. The assigned independent review organization shall\n\nterminate the external review upon receipt of the\n\nnotice from the health carrier sent pursuant to\n\nsubparagraph a of this paragraph.\n\nH. 1. Except as provided in paragraph 3 of this subsection,\n\nwithin twenty (20) days after being selected in accordance with\n\nsubsection D of this section to conduct the external review, each\n\nclinical reviewer shall provide an opinion to the assigned\n\nindependent review organization pursuant to subsection I of this\n\nsection on whether the recommended or requested health care service\n\nor treatment should be covered.\n\n2. Except for an opinion provided pursuant to paragraph 3 of\n\nthis subsection, each clinical reviewer's opinion shall be in\n\nwriting and include the following information:\n\na. a description of the covered person's medical\n\ncondition,\n\nb. a description of the indicators relevant to\n\ndetermining whether there is sufficient evidence to\n\ndemonstrate that the recommended or requested health\n\ncare service or treatment is more likely than not to\n\nbe beneficial to the covered person than any available\n\nstandard health care services or treatments and the\n\nadverse risks of the recommended or requested health\n\ncare service or treatment would not be substantially\n\nincreased over those of available standard health care\n\nservices or treatments,\n\nc. a description and analysis of any medical or\n\nscientific evidence, as that term is defined in\n\nSection 6475.3 of this title, considered in reaching\n\nthe opinion,\n\nd. a description and analysis of any evidence-based\n\nstandard, as that term is defined in Section 6475.3 of\n\nthis title, and\n\ne. information on whether the reviewer's rationale for\n\nthe opinion is based on subparagraph a or b of\n\nparagraph 5 of subsection I of this section.\n\n3. a. For an expedited external review, each clinical\n\nreviewer shall provide an opinion orally or in writing\n\nto the assigned independent review organization as\n\nexpeditiously as the covered person's medical\n\ncondition or circumstances require, but in no event\n\nmore than five (5) calendar days after being selected\nn is based on subparagraph a or b of\n\nparagraph 5 of subsection I of this section.\n\n3. a. For an expedited external review, each clinical\n\nreviewer shall provide an opinion orally or in writing\n\nto the assigned independent review organization as\n\nexpeditiously as the covered person's medical\n\ncondition or circumstances require, but in no event\n\nmore than five (5) calendar days after being selected\n\nin accordance with subsection D of this section.\n\nb. If the opinion provided pursuant to subparagraph a of\n\nthis paragraph was not in writing, within forty-eight\n\n(48) hours following the date the opinion was provided\n\nthe clinical reviewer shall provide written\n\nconfirmation of the opinion to the assigned\n\nindependent review organization and include the\n\ninformation required under paragraph 2 of this\n\nsubsection.\n\nI. In addition to the documents and information provided\n\npursuant to paragraph 2 of subsection A of this section or\n\nsubsection E of this section, each clinical reviewer selected\n\npursuant to subsection D of this section, to the extent the\n\ninformation or documents are available and the reviewer considers\n\nappropriate, shall consider the following in reaching an opinion\n\npursuant to subsection H of this section:\n\n1. The covered person's pertinent medical records;\n\n2. The attending physician or health care professional's\n\nrecommendation;\n\n3. Consulting reports from appropriate health care\n\nprofessionals and other documents submitted by the health carrier,\n\ncovered person, the covered person's authorized representative, or\n\nthe covered person's treating physician or health care professional;\n\n4. The terms of coverage under the covered person's health\n\nbenefit plan with the health carrier to ensure that, but for the\n\nhealth carrier's determination that the recommended or requested\n\nhealth care service or treatment that is the subject of the opinion\n\nis experimental or investigational, the reviewer's opinion is not\n\ncontrary to the terms of coverage under the covered person's health\n\nbenefit plan with the health carrier; and\n\n5. Whether:\n\na. the recommended or requested health care service or\n\ntreatment has been approved by the federal Food and\n\nDrug Administration, if applicable, for the condition,\n\nor\n\nb. medical or scientific evidence or evidence-based\n\nstandards demonstrate that the expected benefits of\n\nthe recommended or requested health care service or\n\ntreatment is more likely than not to be beneficial to\n\nthe covered person than any available standard health\n\ncare service or treatment and the adverse risks of the\n\nrecommended or requested health care service or\n\ntreatment would not be substantially increased over\n\nthose of available standard health care services or\n\ntreatments.\n\nJ. 1. a. Except as provided in subparagraph b of this\n\nparagraph, within twenty (20) days after the date it\n\nreceives the opinion of each clinical reviewer\n\npursuant to subsection I of this section, the assigned\n\nindependent review organization, in accordance with\n\nparagraph 2 of this subsection, shall make a decision\n\nand provide written notice of the decision to:\n\n(1) the covered person,\n\n(2) if applicable, the covered person's authorized\n\nrepresentative,\n\n(3) the health carrier, and\n\n(4) the Commissioner.\n\nb. (1) For an expedited external review, within forty-\n\neight (48) hours after the date it receives the\n\nopinion of each clinical reviewer pursuant to\n\nsubsection I of this section, the assigned\n\nindependent review organization, in accordance\n\nwith paragraph 2 of this subsection, shall make a\n\ndecision and provide notice of the decision\n\norally or in writing to the persons listed in\n\nsubparagraph a of this paragraph.\nted external review, within forty-\n\neight (48) hours after the date it receives the\n\nopinion of each clinical reviewer pursuant to\n\nsubsection I of this section, the assigned\n\nindependent review organization, in accordance\n\nwith paragraph 2 of this subsection, shall make a\n\ndecision and provide notice of the decision\n\norally or in writing to the persons listed in\n\nsubparagraph a of this paragraph.\n\n(2) If the notice provided under division (1) of this\n\nsubparagraph was not in writing, within forty-\n\neight (48) hours after the date of providing that\n\nnotice, the assigned independent review\n\norganization shall provide written confirmation\n\nof the decision to the persons listed in\n\nsubparagraph a of this paragraph and include the\n\ninformation set forth in paragraph 3 of this\n\nsubsection.\n\n2. a. If a majority of the clinical reviewers recommend that\n\nthe recommended or requested health care service or\n\ntreatment should be covered, the independent review\n\norganization shall make a decision to reverse the\n\nhealth carrier's adverse determination or final\n\nadverse determination.\n\nb. If a majority of the clinical reviewers recommend that\n\nthe recommended or requested health care service or\n\ntreatment should not be covered, the independent\n\nreview organization shall make a decision to uphold\n\nthe health carrier's adverse determination or final\n\nadverse determination.\n\nc. (1) If the clinical reviewers are evenly split as to\n\nwhether the recommended or requested health care\n\nservice or treatment should be covered, the\n\nindependent review organization shall obtain the\n\nopinion of an additional clinical reviewer in\n\norder for the independent review organization to\n\nmake a decision based on the opinions of a\n\nmajority of the clinical reviewers pursuant to\n\nsubparagraph a or b of this paragraph.\n\n(2) The additional clinical reviewer selected under\n\ndivision (1) of this subparagraph shall use the\n\nsame information to reach an opinion as the\n\nclinical reviewers who have already submitted\n\ntheir opinions pursuant to subsection I of this\n\nsection.\n\n(3) The selection of the additional clinical reviewer\n\nunder this subparagraph shall not extend the time\n\nwithin which the assigned independent review\n\norganization is required to make a decision based\n\non the opinions of the clinical reviewers\n\nselected pursuant to paragraph 1 of subsection D\n\nof this section.\n\n3. The independent review organization shall include in the\n\nnotice provided pursuant to paragraph 1 of this subsection:\n\na. a general description of the reason for the request\n\nfor external review,\n\nb. the written opinion of each clinical reviewer\n\nincluding the recommendation of each clinical reviewer\n\nas to whether the recommended or requested health care\n\nservice or treatment should be covered and the\n\nrationale for the reviewer's recommendation,\n\nc. the date the independent review organization was\n\nassigned by the Commissioner to conduct the external\n\nreview,\n\nd. the date the external review was conducted,\n\ne. the date of its decision,\n\nf. the principal reason or reasons for its decision, and\n\ng. the rationale for its decision.\n\n4. Upon receipt of a notice of a decision pursuant to paragraph\n\n1 of this subsection reversing the adverse determination or final\n\nadverse determination, the health carrier immediately shall approve\n\ncoverage of the recommended or requested health care service or\n\ntreatment that was the subject of the adverse determination or final\n\nadverse determination.\n\nK. The assignment by the Commissioner of an approved\n\nindependent review organization to conduct an external review in\n\naccordance with this section shall be done on a random basis among\n\nthose approved independent review organizations qualified to conduct\n\nthe particular external review based on the nature of the health\n\ncare service that is the subject of the adverse determination or\nrmination.\n\nK. The assignment by the Commissioner of an approved\n\nindependent review organization to conduct an external review in\n\naccordance with this section shall be done on a random basis among\n\nthose approved independent review organizations qualified to conduct\n\nthe particular external review based on the nature of the health\n\ncare service that is the subject of the adverse determination or\n\nfinal adverse determination and other circumstances including\n\nconflict of interest concerns pursuant to subsection D of Section\n\n6475.13 of this title.","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":"22df9be5ce3fa6ab4f69c25d70de72264ff5a288594feafa9a244187ec08078c","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.1","next":"us-ok/okla.-stat.-tit.-36-36-6475.11"},"notice":"GroundRules: Original legal text. Not legal advice."}