{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.13","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.13","heading":"Eligibility requirements","body":"A. To be approved under Section 6475.12 of this title to\n\nconduct external reviews, an independent review organization shall\n\nhave and maintain written policies and procedures that govern all\n\naspects of both the standard external review process and the\n\nexpedited external review process set forth in this act that\n\ninclude, at a minimum:\n\n1. A quality assurance mechanism in place that:\n\na. ensures that external reviews are conducted within the\n\nspecified time frames and required notices are\n\nprovided in a timely manner,\n\nb. ensures the selection of qualified and impartial\n\nclinical reviewers to conduct external reviews on\n\nbehalf of the independent review organization and\n\nsuitable matching of reviewers to specific cases and\n\nthat the independent review organization employs or\n\ncontracts with an adequate number of clinical\n\nreviewers to meet this objective,\n\nc. ensures the confidentiality of medical and treatment\n\nrecords and clinical review criteria, and\n\nd. ensures that any person employed by or under contract\n\nwith the independent review organization adheres to\n\nthe requirements of the Uniform Health Carrier\n\nExternal Review Act;\n\n2. A toll-free telephone service to receive information on a\n\ntwenty-four-hour-a-day, seven-day-a-week basis related to external\n\nreviews that is capable of accepting, recording or providing\n\nappropriate instruction to incoming telephone callers during other\n\nthan normal business hours; and\n\n3. Agree to maintain and provide to the Insurance Commissioner\n\nthe information set out in Section 6475.15 of this title.\n\nB. All clinical reviewers assigned by an independent review\n\norganization to conduct external reviews shall be physicians or\n\nother appropriate health care providers who meet the following\n\nminimum qualifications:\n\n1. Be an expert in the treatment of the covered person's\n\nmedical condition that is the subject of the external review;\n\n2. Be knowledgeable about the recommended health care service\n\nor treatment through recent or current actual clinical experience\n\ntreating patients with the same or similar medical condition of the\n\ncovered person;\n\n3. Hold a nonrestricted license in a state of the United States\n\nand, for physicians, a current certification by a recognized\n\nAmerican medical specialty board in the area or areas appropriate to\n\nthe subject of the external review; and\n\n4. Have no history of disciplinary actions or sanctions,\n\nincluding loss of staff privileges or participation restrictions,\n\nthat have been taken or are pending by any hospital, governmental\n\nagency or unit, or regulatory body that raise a substantial question\n\nas to the clinical reviewer's physical, mental or professional\n\ncompetence or moral character.\n\nC. In addition to the requirements set forth in subsection A of\n\nthis section, an independent review organization may not own or\n\ncontrol, be a subsidiary of or in any way be owned or controlled by,\n\nor exercise control with a health benefit plan, a national, state or\n\nlocal trade association of health benefit plans, or a national,\n\nstate or local trade association of health care providers.\n\nD. 1. In addition to the requirements set forth in subsections\n\nA, B and C of this section, to be approved pursuant to Section\n\n6475.12 of this title to conduct an external review of a specified\n\ncase, neither the independent review organization selected to\n\nconduct the external review nor any clinical reviewer assigned by\n\nthe independent organization to conduct the external review may have\n\na material professional, familial or financial conflict of interest\n\nwith any of the following:\n\na. the health carrier that is the subject of the external\n\nreview,\n\nb. the covered person whose treatment is the subject of\n\nthe external review or the covered person's authorized\n\nrepresentative,\n\nc. any officer, director or management employee of the\n\nhealth carrier that is the subject of the external\n\nreview,\nprofessional, familial or financial conflict of interest\n\nwith any of the following:\n\na. the health carrier that is the subject of the external\n\nreview,\n\nb. the covered person whose treatment is the subject of\n\nthe external review or the covered person's authorized\n\nrepresentative,\n\nc. any officer, director or management employee of the\n\nhealth carrier that is the subject of the external\n\nreview,\n\nd. the health care provider, the health care provider's\n\nmedical group or independent practice association\n\nrecommending the health care service or treatment that\n\nis the subject of the external review,\n\ne. the facility at which the recommended health care\n\nservice or treatment would be provided, or\n\nf. the developer or manufacturer of the principal drug,\n\ndevice, procedure or other therapy being recommended\n\nfor the covered person whose treatment is the subject\n\nof the external review.\n\n2. In determining whether an independent review organization or\n\na clinical reviewer of the independent review organization has a\n\nmaterial professional, familial or financial conflict of interest\n\nfor purposes of paragraph 1 of this subsection, the Commissioner\n\nshall take into consideration situations where the independent\n\nreview organization to be assigned to conduct an external review of\n\na specified case or a clinical reviewer to be assigned by the\n\nindependent review organization to conduct an external review of a\n\nspecified case may have an apparent professional, familial or\n\nfinancial relationship or connection with a person described in\n\nparagraph 1 of this subsection, but that the characteristics of that\n\nrelationship or connection are such that they are not a material\n\nprofessional, familial or financial conflict of interest that\n\nresults in the disapproval of the independent review organization or\n\nthe clinical reviewer from conducting the external review.\n\nE. In addition to the requirements set forth in subsections A,\n\nB, C and D of this section, an independent review organization shall\n\npossess any additional minimum qualifications that the Insurance\n\nCommissioner may promulgate by rule.\n\nF. 1. An independent review organization that is accredited by\n\na nationally recognized private accrediting entity that has\n\nindependent review accreditation standards that the Commissioner has\n\ndetermined are equivalent to or exceed the minimum qualifications of\n\nthis section shall be presumed in compliance with this section to be\n\neligible for approval under Section 6475.12 of this title. If a\n\nnationally recognized private accrediting entity has independent\n\nreview accreditation standards that are substantially similar to but\n\ndo not equal or exceed the minimum qualifications of this section,\n\nthe Commissioner may accept the accreditation as an equivalent\n\naccreditation standard after reviewing for compliance any minimum\n\nqualifications required by this section that are not required by the\n\nnational accreditation.\n\n2. The Commissioner shall initially review and periodically\n\nreview the independent review organization accreditation standards\n\nof a nationally recognized private accrediting entity to determine\n\nwhether the entity's standards are, and continue to be, equivalent\n\nto or exceed the minimum qualifications established under this\n\nsection. The Commissioner may accept a review conducted by the NAIC\n\nfor the purpose of the determination under this paragraph.\n\n3. Upon request, a nationally recognized private accrediting\n\nentity shall make its current independent review organization\n\naccreditation standards available to the Commissioner or the NAIC in\n\norder for the Commissioner to determine if the entity's standards\n\nare equivalent to or exceed the minimum qualifications established\n\nunder this section. The Commissioner may exclude any private\n\naccrediting entity that is not reviewed by the NAIC.\nependent review organization\n\naccreditation standards available to the Commissioner or the NAIC in\n\norder for the Commissioner to determine if the entity's standards\n\nare equivalent to or exceed the minimum qualifications established\n\nunder this section. The Commissioner may exclude any private\n\naccrediting entity that is not reviewed by the NAIC.\n\nG. An independent review organization shall be unbiased. An\n\nindependent review organization shall establish and maintain written\n\nprocedures to ensure that it is unbiased in addition to any other\n\nprocedures required under this section.","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":"466e2ef20d2ba4862f80853b33c68cdfc1d151a4f926c7cf92dace1d2491281d","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.12","next":"us-ok/okla.-stat.-tit.-36-36-6475.14"},"notice":"GroundRules: Original legal text. Not legal advice."}