{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.7","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.7","heading":"External review procedure","body":"A. 1. Except as provided in subsection B of this section, a\n\nrequest for an external review pursuant to Section 6475.8, 6475.9,\n\nor 6475.10 of this title shall not be made until the covered person\n\nhas exhausted the health carrier's internal grievance process.\n\n2. A covered person shall be considered to have exhausted the\n\nhealth carrier's internal grievance process for purposes of this\n\nsection, if the covered person or the covered person's authorized\n\nrepresentative:\n\na. has filed a grievance involving an adverse\n\ndetermination, and\n\nb. except to the extent the covered person or the covered\n\nperson's authorized representative requested or agreed\n\nto a delay, has not received a written decision on the\n\ngrievance from the health carrier within thirty (30)\n\ndays following the date the covered person or the\n\ncovered person's authorized representative filed the\n\ngrievance with the health carrier.\n\n3. Notwithstanding paragraph 2 of this subsection, a covered\n\nperson or the covered person's authorized representative may not\n\nmake a request for an external review of an adverse determination\n\ninvolving a retrospective review determination made pursuant to\n\nSections 6551 through 6565 of this title until the covered person\n\nhas exhausted the health carrier's internal grievance process.\n\nB. 1. a. At the same time a covered person or the covered\n\nperson's authorized representative files a request for\n\nan expedited review of a grievance involving an\n\nadverse determination, the covered person or the\n\ncovered person's authorized representative may file a\n\nrequest for an expedited external review of the\n\nadverse determination:\n\n(1) under Section 6475.9 of this title if the covered\n\nperson has a medical condition where the time\n\nframe for completion of an expedited review of\n\nthe grievance involving an adverse determination\n\nwould seriously jeopardize the life or health of\n\nthe covered person or would jeopardize the\n\ncovered person's ability to regain maximum\n\nfunction, or\n\n(2) under Section 6475.10 of this title if the\n\nadverse 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.\n\nb. Upon receipt of a request for an expedited external\n\nreview under subparagraph a of this paragraph, the\n\nindependent review organization conducting the\n\nexternal review in accordance with the provisions of\n\nSection 6475.9 or 6475.10 of this title shall\n\ndetermine whether the covered person shall be required\n\nto complete the expedited review process before it\n\nconducts the expedited external review.\n\nc. Upon a determination made pursuant to subparagraph b\n\nof this paragraph that the covered person must first\n\ncomplete the expedited grievance review process, the\n\nindependent review organization immediately shall\n\nnotify the covered person and, if applicable, the\n\ncovered person's authorized representative of this\n\ndetermination and that it will not proceed with the\n\nexpedited external review set forth in Section 6475.9\n\nof this title until completion of the expedited\n\ngrievance review process and the covered person's\n\ngrievance at the completion of the expedited grievance\n\nreview process remains unresolved.\n\n2. A request for an external review of an adverse determination\n\nmay be made before the covered person has exhausted the health\n\ncarrier's internal grievance procedures whenever the health carrier\n\nagrees to waive the exhaustion requirement.\n\nC. If the requirement to exhaust the health carrier's internal\n\ngrievance procedures is waived under paragraph 2 of subsection B of\ncess remains unresolved.\n\n2. A request for an external review of an adverse determination\n\nmay be made before the covered person has exhausted the health\n\ncarrier's internal grievance procedures whenever the health carrier\n\nagrees to waive the exhaustion requirement.\n\nC. If the requirement to exhaust the health carrier's internal\n\ngrievance procedures is waived under paragraph 2 of subsection B of\n\nthis section, the covered person or the covered person's authorized\n\nrepresentative may file a request in writing for a standard external\n\nreview as set forth in Section 6475.8 or 6475.10 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":"1d4b2e6dc84a1d0094369ef3b5e26e3b6a88f6614834a16db136e863af0a6d2e","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.6","next":"us-ok/okla.-stat.-tit.-36-36-6475.8"},"notice":"GroundRules: Original legal text. Not legal advice."}