{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.3","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.3","heading":"Definitions","body":"For purposes of the Uniform Health Carrier External Review Act:\n\n1. “Adverse determination” means a determination by a health\n\ncarrier or its designee utilization review organization that an\n\nadmission, availability of care, continued stay or other health care\n\nservice that is a covered benefit has been reviewed and, based upon\n\nthe information provided, does not meet the health carrier’s\n\nrequirements for medical necessity, appropriateness, health care\n\nsetting, level of care or effectiveness, and the requested service\n\nor payment for the service is therefore denied, reduced or\n\nterminated;\n\n2. “Ambulatory review” means utilization review of health care\n\nservices performed or provided in an outpatient setting;\n\n3. “Authorized representative” means:\n\na. a person to whom a covered person has given express\n\nwritten consent to represent the covered person in an\n\nexternal review,\n\nb. a person authorized by law to provide substituted\n\nconsent for a covered person, or\n\nc. a family member of the covered person or the covered\n\nperson’s treating health care professional only when\n\nthe covered person is unable to provide consent;\n\n4. “Best evidence” means evidence based on:\n\na. randomized clinical trials,\n\nb. if randomized clinical trials are not available,\n\ncohort studies or case-control studies,\n\nc. if subparagraphs a and b of this paragraph are not\n\navailable, case-series, or\n\nd. if subparagraphs a, b and c of this paragraph are not\n\navailable, expert opinion;\n\n5. “Case-control study” means a retrospective evaluation of two\n\ngroups of patients with different outcomes to determine which\n\nspecific interventions the patients received;\n\n6. “Case management” means a coordinated set of activities\n\nconducted for individual patient management of serious, complicated,\n\nprotracted or other health conditions;\n\n7. “Case-series” means an evaluation of a series of patients\n\nwith a particular outcome, without the use of a control group;\n\n8. “Certification” means a determination by a health carrier or\n\nits designee utilization review organization that an admission,\n\navailability of care, continued stay or other health care service\n\nhas been reviewed and, based on the information provided, satisfies\n\nthe health carrier’s requirements for medical necessity,\n\nappropriateness, health care setting, level of care and\n\neffectiveness;\n\n9. “Clinical review criteria” means the written screening\n\nprocedures, decision abstracts, clinical protocols and practice\n\nguidelines used by a health carrier to determine the necessity and\n\nappropriateness of health care services;\n\n10. “Cohort study” means a prospective evaluation of two groups\n\nof patients with only one group of patients receiving a specific\n\nintervention or specific interventions;\n\n11. “Commissioner” means the Insurance Commissioner;\n\n12. “Concurrent review” means utilization review conducted\n\nduring a hospital stay or course of treatment of a patient;\n\n13. “Covered benefits” or “benefits” means those health care\n\nservices to which a covered person is entitled under the terms of a\n\nhealth benefit plan;\n\n14. “Covered person” means a policyholder, subscriber, enrollee\n\nor other individual participating in a health benefit plan;\n\n15. “Discharge planning” means the formal process for\n\ndetermining, prior to discharge from a facility, the coordination\n\nand management of the care that a patient receives following\n\ndischarge from a facility;\n\n16. “Disclose” means to release, transfer or otherwise divulge\n\nprotected health information to any person other than the individual\n\nwho is the subject of the protected health information;\n\n17. “Emergency medical condition” means the sudden and, at the\n\ntime, unexpected onset of a health condition or illness that\n\nrequires immediate medical attention, where failure to provide\n\nmedical attention would result in a serious impairment to bodily\nany person other than the individual\n\nwho is the subject of the protected health information;\n\n17. “Emergency medical condition” means the sudden and, at the\n\ntime, unexpected onset of a health condition or illness that\n\nrequires immediate medical attention, where failure to provide\n\nmedical attention would result in a serious impairment to bodily\n\nfunctions, serious dysfunction of a bodily organ or part, or would\n\nplace the person’s health in serious jeopardy;\n\n18. “Emergency services” means health care items and services\n\nfurnished or required to evaluate and treat an emergency medical\n\ncondition;\n\n19. “Evidence-based standard” means the conscientious, explicit\n\nand judicious use of the current best evidence based on the overall\n\nsystematic review of the research in making decisions about the care\n\nof individual patients;\n\n20. “Expert opinion” means a belief or an interpretation by\n\nspecialists with experience in a specific area about the scientific\n\nevidence pertaining to a particular service, intervention or\n\ntherapy;\n\n21. “Facility” means an institution providing health care\n\nservices or a health care setting, including but not limited to\n\nhospitals and other licensed inpatient centers, ambulatory surgical\n\nor treatment centers, skilled nursing centers, residential treatment\n\ncenters, diagnostic, laboratory and imaging centers, and\n\nrehabilitation and other therapeutic health settings;\n\n22. “Final adverse determination” means an adverse\n\ndetermination involving a covered benefit that has been upheld by a\n\nhealth carrier, or its designee utilization review organization, at\n\nthe completion of the health carrier’s internal grievance process\n\nprocedures;\n\n23. “Health benefit plan” means a policy, contract, certificate\n\nor agreement offered or issued by a health carrier to provide,\n\ndeliver, arrange for, pay for or reimburse any of the costs of\n\nhealth care services;\n\n24. “Health care professional” means a physician or other\n\nhealth care practitioner licensed, accredited or certified to\n\nperform specified health care services consistent with state law;\n\n25. “Health care provider” or “provider” means a health care\n\nprofessional or a facility;\n\n26. “Health care services” means services for the diagnosis,\n\nprevention, treatment, cure or relief of a health condition,\n\nillness, injury or disease;\n\n27. “Health carrier” means an entity subject to the insurance\n\nlaws and regulations of this state, or subject to the jurisdiction\n\nof the Commissioner, that contracts or offers to contract to\n\nprovide, deliver, arrange for, pay for or reimburse any of the costs\n\nof health care services, including but not limited to a sickness and\n\naccident insurance company, a health maintenance organization, a\n\nnonprofit hospital and health service corporation, or any other\n\nentity providing a plan of health insurance, health benefits or\n\nhealth care services;\n\n28. “Health information” means information or data, whether\n\noral or recorded in any form or medium, and personal facts or\n\ninformation about events or relationships that relate to:\n\na. the past, present or future physical, mental, or\n\nbehavioral health or condition of an individual or a\n\nmember of the individual’s family,\n\nb. the provision of health care services to an\n\nindividual, or\n\nc. payment for the provision of health care services to\n\nan individual;\n\n29. “Independent review organization” means an entity that\n\nconducts independent external reviews of adverse determinations and\n\nfinal adverse determinations;\n\n30. “Medical or scientific evidence” means evidence found in\n\nthe following sources:\n\na. peer-reviewed scientific studies published in or\n\naccepted for publication by medical journals that meet\n\nnationally recognized requirements for scientific\n\nmanuscripts and that submit most of the published\n\narticles for review by experts who are not part of the\n\neditorial staff,\nfinal adverse determinations;\n\n30. “Medical or scientific evidence” means evidence found in\n\nthe following sources:\n\na. peer-reviewed scientific studies published in or\n\naccepted for publication by medical journals that meet\n\nnationally recognized requirements for scientific\n\nmanuscripts and that submit most of the published\n\narticles for review by experts who are not part of the\n\neditorial staff,\n\nb. peer-reviewed medical literature, including literature\n\nrelating to therapies reviewed and approved by a\n\nqualified institutional review board, biomedical\n\ncompendia and other medical literature that meet the\n\ncriteria of the National Institutes of Health’s\n\nLibrary of Medicine for indexing in Index Medicus\n\n(Medline) and Elsevier Science Ltd. for indexing in\n\nExcerpta Medicus (EMBASE),\n\nc. medical journals recognized by the Secretary of Health\n\nand Human Services under Section 1861(t)(2) of the\n\nfederal Social Security Act,\n\nd. the following standard reference compendia:\n\n(1) the American Hospital Formulary Service–Drug\n\nInformation,\n\n(2) Drug Facts and Comparisons,\n\n(3) the American Dental Association Accepted Dental\n\nTherapeutics, and\n\n(4) the United States Pharmacopoeia–Drug Information,\n\ne. findings, studies or research conducted by or under\n\nthe auspices of federal government agencies and\n\nnationally recognized federal research institutes,\n\nincluding but not limited to:\n\n(1) the federal Agency for Healthcare Research and\n\nQuality,\n\n(2) the National Institutes of Health,\n\n(3) the National Cancer Institute,\n\n(4) the National Academy of Sciences,\n\n(5) the Centers for Medicare and Medicaid Services,\n\n(6) the federal Food and Drug Administration, and\n\n(7) any national board recognized by the National\n\nInstitutes of Health for the purpose of\n\nevaluating the medical value of health care\n\nservices, or\n\nf. any other medical or scientific evidence that is\n\ncomparable to the sources listed in subparagraphs a\n\nthrough e of this paragraph;\n\n31. “NAIC” means the National Association of Insurance\n\nCommissioners;\n\n32. “Person” means an individual, a corporation, a partnership,\n\nan association, a joint venture, a joint stock company, a trust, an\n\nunincorporated organization, any similar entity or any combination\n\nof the foregoing;\n\n33. “Prospective review” means utilization review conducted\n\nprior to an admission or a course of treatment;\n\n34. “Protected health information” means health information:\n\na. that identifies an individual who is the subject of\n\nthe information, or\n\nb. with respect to which there is a reasonable basis to\n\nbelieve that the information could be used to identify\n\nan individual;\n\n35. “Randomized clinical trial” means a controlled, prospective\n\nstudy of patients that have been randomized into an experimental\n\ngroup and a control group at the beginning of the study with only\n\nthe experimental group of patients receiving a specific\n\nintervention, which includes study of the groups for variables and\n\nanticipated outcomes over time;\n\n36. “Retrospective review” means a review of medical necessity\n\nconducted after services have been provided to a patient, but does\n\nnot include the review of a claim that is limited to an evaluation\n\nof reimbursement levels, veracity of documentation, accuracy of\n\ncoding or adjudication for payment;\n\n37. “Second opinion” means an opportunity or requirement to\n\nobtain a clinical evaluation by a provider other than the one\n\noriginally making a recommendation for a proposed health care\n\nservice to assess the clinical necessity and appropriateness of the\n\ninitial proposed health care service;\n\n38. “Utilization review” means a set of formal techniques\n\ndesigned to monitor the use of, or evaluate the clinical necessity,\n\nappropriateness, efficacy, or efficiency of, health care services,\n\nprocedures, or settings. Techniques may include but are not limited\n\nto ambulatory review, prospective review, second opinion,\nnecessity and appropriateness of the\n\ninitial proposed health care service;\n\n38. “Utilization review” means a set of formal techniques\n\ndesigned to monitor the use of, or evaluate the clinical necessity,\n\nappropriateness, efficacy, or efficiency of, health care services,\n\nprocedures, or settings. Techniques may include but are not limited\n\nto ambulatory review, prospective review, second opinion,\n\ncertification, concurrent review, case management, discharge\n\nplanning, or retrospective review; and\n\n39. “Utilization review organization” means an entity that\n\nconducts utilization review, other than a health carrier performing\n\na review for its own health benefit plans.","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":"c4e7fd36c82ef7e6d1554845406439d3f12f6db666e78b854baf4209a8bcd240","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.2","next":"us-ok/okla.-stat.-tit.-36-36-6475.4"},"notice":"GroundRules: Original legal text. Not legal advice."}