{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.5","heading":"External review","body":"A. 1. A health carrier shall notify the covered person in\n\nwriting of the covered person's right to request an external review\n\nto be conducted pursuant to Section 6475.8, 6475.9, or 6475.10 of\n\nthis title and include the appropriate statements and information\n\nset forth in subsection B of this section at the same time the\n\nhealth carrier sends written notice of:\n\na. an adverse determination upon completion of the health\n\ncarrier's utilization review process set forth in\n\nSections 6551 through 6565 of this title, and\n\nb. a final adverse determination.\n\n2. As part of the written notice required under paragraph 1 of\n\nthis subsection, a health carrier shall include the following, or\n\nsubstantially equivalent, language: \"We have denied your request\n\nfor the provision of or payment for a health care service or course\n\nof treatment. You may have the right to have our decision reviewed\n\nby health care professionals who have no association with us if our\n\ndecision involved making a judgment as to the medical necessity,\n\nappropriateness, health care setting, level of care or effectiveness\n\nof the health care service or treatment you requested by submitting\n\na request for external review to the Oklahoma Insurance Department.\"\n\n3. The Insurance Commissioner may promulgate any necessary rule\n\nproviding for the form and content of the notice required under this\n\nsection.\n\nB. 1. The health carrier shall include in the notice required\n\nunder subsection A of this section:\n\na. for a notice related to an adverse determination, a\n\nstatement informing the covered person that:\n\n(1) if the covered person has a medical condition\n\nwhere the time frame for completion of an\n\nexpedited review of a grievance involving an\n\nadverse determination would seriously jeopardize\n\nthe life or health of the covered person or would\n\njeopardize the covered person's ability to regain\n\nmaximum function, the covered person or the\n\ncovered person's authorized representative may\n\nfile a request for an expedited external review\n\nto be conducted pursuant to Section 6475.10 of\n\nthis title, or Section 6475.11 of this title if\n\nthe adverse determination involves a denial of\n\ncoverage based on a determination that the\n\nrecommended or requested health care service or\n\ntreatment is experimental or investigational and\n\nthe covered person's treating physician certifies\n\nin writing that the recommended or requested\n\nhealth care service or treatment that is the\n\nsubject of the adverse determination would be\n\nsignificantly less effective if not promptly\n\ninitiated, at the same time the covered person or\n\nthe covered person's authorized representative\n\nfiles a request for an expedited review of a\n\ngrievance involving an adverse determination, but\n\nthat the independent review organization assigned\n\nto conduct the expedited external review will\n\ndetermine whether the covered person shall be\n\nrequired to complete the expedited review of the\n\ngrievance prior to conducting the expedited\n\nexternal review, and\novered person's authorized representative\n\nfiles a request for an expedited review of a\n\ngrievance involving an adverse determination, but\n\nthat the independent review organization assigned\n\nto conduct the expedited external review will\n\ndetermine whether the covered person shall be\n\nrequired to complete the expedited review of the\n\ngrievance prior to conducting the expedited\n\nexternal review, and\n\n(2) the covered person or the covered person's\n\nauthorized representative may file a grievance\n\nunder the health carrier's internal grievance\n\nprocess, but if the health carrier has not issued\n\na written decision to the covered person or the\n\ncovered person's authorized representative within\n\nthirty (30) days following the date the covered\n\nperson or the covered person's authorized\n\nrepresentative files the grievance with the\n\nhealth carrier and the covered person or the\n\ncovered person's authorized representative has\n\nnot requested or agreed to a delay, the covered\n\nperson or the covered person's authorized\n\nrepresentative may file a request for external\n\nreview pursuant to Section 6475.6 of this title\n\nand shall be considered to have exhausted the\n\nhealth carrier's internal grievance process for\n\npurposes of Section 6475.7 of this title, and\n\nb. for a notice related to a final adverse determination,\n\na statement informing the covered person that:\n\n(1) if the covered person has a medical condition\n\nwhere the time frame for completion of a standard\n\nexternal review pursuant to Section 6475.8 of\n\nthis title would seriously jeopardize the life or\n\nhealth of the covered person or would jeopardize\n\nthe covered person's ability to regain maximum\n\nfunction, the covered person or the covered\n\nperson's authorized representative may file a\n\nrequest for an expedited external review pursuant\n\nto Section 6475.9 of this title, or\n\n(2) if the final adverse determination concerns:\n\n(a) an admission, availability of care,\n\ncontinued stay or health care service for\n\nwhich the covered person received emergency\n\nservices, but has not been discharged from a\n\nfacility, the covered person or the covered\n\nperson's authorized representative may\n\nrequest an expedited external review\n\npursuant to Section 6475.9 of this title, or\n\n(b) a denial of coverage based on a\n\ndetermination that the recommended or\n\nrequested health care service or treatment\n\nis experimental or investigational, the\n\ncovered person or the covered person's\n\nauthorized representative may file a request\n\nfor a standard external review to be\n\nconducted pursuant to Section 6475.10 of\n\nthis title or if the covered person's\n\ntreating physician certifies in writing that\n\nthe recommended or requested health care\n\nservice or treatment that is the subject of\n\nthe request would be significantly less\n\neffective if not promptly initiated, the\n\ncovered person or the covered person's\n\nauthorized representative may request an\n\nexpedited external review to be conducted\n\nunder Section 6475.10 of this title.\n\n2. In addition to the information to be provided pursuant to\n\nparagraph 1 of this subsection, the health carrier shall include a\n\ncopy of the description of both the standard and expedited external\n\nreview procedures the health carrier is required to provide pursuant\n\nto Section 6475.17 of this title, highlighting the provisions in the\n\nexternal review procedures that give the covered person or the\n\ncovered person's authorized representative the opportunity to submit\n\nadditional information and including any forms used to process an\n\nexternal review.\n\n3. As part of any forms provided under paragraph 2 of this\n\nsubsection, the health carrier shall include an authorization form,\n\nor other document approved by the Commissioner that complies with\n\nthe requirements of 45 CFR, Section 164.508, by which the covered\n\nperson, for purposes of conducting an external review under this\nnformation and including any forms used to process an\n\nexternal review.\n\n3. As part of any forms provided under paragraph 2 of this\n\nsubsection, the health carrier shall include an authorization form,\n\nor other document approved by the Commissioner that complies with\n\nthe requirements of 45 CFR, Section 164.508, by which the covered\n\nperson, for purposes of conducting an external review under this\n\nact, authorizes the health carrier and the covered person's treating\n\nhealth care provider to disclose protected health information\n\nincluding medical records, concerning the covered person that are\n\npertinent to the external review.","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":"7d706f47c305ea6bd061f10481f7a2906acb517076ae5aa459a70a993b7ef2df","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.4","next":"us-ok/okla.-stat.-tit.-36-36-6475.6"},"notice":"GroundRules: Original legal text. Not legal advice."}