{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.8","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.8","heading":"Receipt of 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, a covered person or the\n\ncovered person's authorized representative may file a request for an\n\nexternal review with the Insurance Commissioner.\n\n2. Within one (1) business day after the date of receipt of a\n\nrequest for external review pursuant to paragraph 1 of this\n\nsubsection, the Commissioner shall send a copy of the request to the\n\nhealth carrier.\n\nB. Within five (5) business days following the date of receipt\n\nof the copy of the external review request from the Commissioner\n\nunder paragraph 2 of subsection A of this section, the health\n\ncarrier shall complete a preliminary review of the request to\n\ndetermine whether:\n\n1. The individual is or was a covered person in the health\n\nbenefit plan at the time the health care service was requested or,\n\nin the case of a retrospective review, was a covered person in the\n\nhealth benefit plan at the time the health care service was\n\nprovided;\n\n2. The health care service that is the subject of the adverse\n\ndetermination or the final adverse determination is a covered\n\nservice under the covered person's health benefit plan, but for a\n\ndetermination by the health carrier that the health care service is\n\nnot covered because it does not meet the health carrier's\n\nrequirements for medical necessity, appropriateness, health care\n\nsetting, level of care or effectiveness;\n\n3. The covered person has exhausted the health carrier's\n\ninternal grievance process unless the covered person is not required\n\nto exhaust the health carrier's internal grievance process pursuant\n\nto Section 6475.7 of this title; and\n\n4. The covered person has provided all the information and\n\nforms required to process an external review including the release\n\nform provided under subsection B of Section 6475.5 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 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 the\n\ncovered person and, if applicable, the covered\n\nperson's authorized representative and the\n\nCommissioner in writing 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, if\n\napplicable, the covered person's authorized\n\nrepresentative and the Commissioner in writing and\n\ninclude in the notice the reasons for its\n\nineligibility.\n\n3. a. The Commissioner may specify the form for the health\n\ncarrier's notice of initial determination under this\n\nsubsection and any supporting information to be\n\nincluded in the notice.\n\nb. The notice of initial determination 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 subsection B of\n\nthis section notwithstanding a health carrier's\n\ninitial determination that the request is ineligible\n\nand require that it be referred for external 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.\ns\n\ninitial determination that the request is ineligible\n\nand require that it be referred for external 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\nD. 1. Whenever the Commissioner receives a notice that a\n\nrequest is eligible for external review following the preliminary\n\nreview conducted pursuant to subsection C of this section, within\n\none (1) business day after the date of receipt of the notice, the\n\nCommissioner shall:\n\na. assign an independent review organization from the\n\nlist of approved independent review organizations\n\ncompiled and maintained by the Commissioner pursuant\n\nto Section 6475.12 of this title to conduct the\n\nexternal review and notify the health carrier of the\n\nname of the assigned independent review organization,\n\nand\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. In reaching a decision, the assigned independent review\n\norganization shall not be bound by any decisions or conclusions\n\nreached during the health carrier's utilization review process as\n\nset forth in Sections 6551 through 6555 of this title or the health\n\ncarrier's internal grievance process.\n\n3. 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\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 final adverse determination.\n\n2. Except as provided in paragraph 3 of this subsection,\n\nfailure by the health carrier or its utilization review organization\n\nto provide the documents and information within the time specified\n\nin paragraph 1 of this subsection shall not delay the conduct of the\n\nexternal review.\n\n3. a. If the health carrier or its utilization review\n\norganization fails to provide the documents and\n\ninformation within the time specified in paragraph 1\n\nof this subsection, the assigned independent review\n\norganization may terminate the external review and\n\nmake a decision to reverse the adverse determination\n\nor final adverse determination.\n\nb. Within one (1) business day after making the decision\n\nunder subparagraph a of this paragraph, the\n\nindependent review organization shall notify the\n\ncovered person, if applicable, the covered person's\n\nauthorized representative, the health carrier, and the\n\nCommissioner.\n\nF. 1. The assigned independent review organization shall\n\nreview all of the information and documents received pursuant to\n\nsubsection E of this section and any other information submitted in\n\nwriting to the independent review organization by the covered person\n\nor the covered person's authorized representative pursuant to\n\nparagraph 3 of subsection D of this section.\n\n2. Upon receipt of any information submitted by the covered\nreview organization shall\n\nreview all of the information and documents received pursuant to\n\nsubsection E of this section and any other information submitted in\n\nwriting to the independent review organization by the covered person\n\nor the covered person's authorized representative pursuant to\n\nparagraph 3 of 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 3 of subsection D of this section, the assigned\n\nindependent review organization shall within one (1) business day\n\nforward the information to the health carrier.\n\nG. 1. Upon receipt of the information, if any, required to be\n\nforwarded pursuant to paragraph 2 of subsection F of this section,\n\nthe health carrier may reconsider its adverse determination or final\n\nadverse determination 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 only be terminated 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 health care service that is the subject\n\nof the adverse determination or final adverse determination.\n\n4. a. Within one (1) business day after making the decision\n\nto reverse its adverse determination or final adverse\n\ndetermination, as provided in paragraph 3 of this\n\nsubsection, the health carrier shall notify the\n\ncovered person, if applicable, the covered person's\n\nauthorized representative, the assigned independent\n\nreview organization, and the Commissioner in writing\n\nof its decision.\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. In addition to the documents and information provided\n\npursuant to subsection E of this section, the assigned independent\n\nreview organization, to the extent the information or documents are\n\navailable and the independent review organization considers them\n\nappropriate, shall consider the following in reaching a decision:\n\n1. The covered person's medical records;\n\n2. The attending health care professional's recommendation;\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 provider;\n\n4. The terms of coverage under the covered person's health\n\nbenefit plan with the health carrier to ensure that the independent\n\nreview organization's decision is not contrary to the terms of\n\ncoverage under the covered person's health benefit plan with the\n\nhealth carrier;\n\n5. The most appropriate practice guidelines, which shall\n\ninclude applicable evidence-based standards and may include any\n\nother practice guidelines developed by the federal government,\n\nnational or professional medical societies, boards and associations;\n\n6. Any applicable clinical review criteria developed and used\n\nby the health carrier or its designee utilization review\n\norganization; and\n\n7. The opinion of the independent review organization's\n\nclinical reviewer or reviewers after considering paragraphs 1\n\nthrough 6 of this subsection to the extent the information or\n\ndocuments are available and the clinical reviewer or reviewers\n\nconsider appropriate.\n\nI. 1. Within forty-five (45) days after the date of receipt of\n\nthe request for an external review, the assigned independent review\n\norganization shall provide written notice of its decision to uphold\n\nor reverse the adverse determination or the final adverse\n\ndetermination to:\n\na. the covered person,\nmation or\n\ndocuments are available and the clinical reviewer or reviewers\n\nconsider appropriate.\n\nI. 1. Within forty-five (45) days after the date of receipt of\n\nthe request for an external review, the assigned independent review\n\norganization shall provide written notice of its decision to uphold\n\nor reverse the adverse determination or the final adverse\n\ndetermination to:\n\na. the covered person,\n\nb. if applicable, the covered person's authorized\n\nrepresentative,\n\nc. the health carrier, and\n\nd. the Commissioner.\n\n2. The independent review organization shall include in the\n\nnotice sent 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 date the independent review organization received\n\nthe assignment from the Commissioner to conduct the\n\nexternal review,\n\nc. the date the external review was conducted,\n\nd. the date of its decision,\n\ne. the principal reason or reasons for its decision\n\nincluding what applicable, if any, evidence-based\n\nstandards were a basis for its decision,\n\nf. the rationale for its decision, and\n\ng. references to the evidence or documentation including\n\nthe evidence-based standards, considered in reaching\n\nits decision.\n\n3. 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\nthe coverage that was the subject of the adverse determination or\n\nfinal adverse determination.\n\nJ. 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":"e156e24b1ef075741922bca7df97c48f126fea3b352e20bf713af455efa9911e","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.7","next":"us-ok/okla.-stat.-tit.-36-36-6475.9"},"notice":"GroundRules: Original legal text. Not legal advice."}