{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6475.9","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6475.9","heading":"Circumstances when external review request can be made","body":"A. Except as provided in subsection F of this section, a\n\ncovered person or the covered person's authorized representative may\n\nmake a request for an expedited external review with the Insurance\n\nCommissioner at the time the covered person receives:\n\n1. An adverse determination if:\n\na. the adverse determination involves a medical condition\n\nof the covered person for which the time frame for\n\ncompletion of an expedited internal review of a\n\ngrievance involving an adverse determination would\n\nseriously jeopardize the life or health of the covered\n\nperson or would jeopardize the covered person's\n\nability to regain maximum function, and\n\nb. the covered person or the covered person's authorized\n\nrepresentative has filed a request for an expedited\n\nreview of a grievance involving an adverse\n\ndetermination; or\n\n2. A final adverse determination:\n\na. if the covered person has a medical condition where\n\nthe time frame for completion of a standard external\n\nreview pursuant to Section 6475.8 of this title would\n\nseriously jeopardize the life or health of the covered\n\nperson or would jeopardize the covered person's\n\nability to regain maximum function, or\n\nb. if the final adverse determination concerns an\n\nadmission, availability of care, continued stay or\n\nhealth care service for which the covered person\n\nreceived emergency services, but has not been\n\ndischarged from a facility.\n\nB. 1. Upon receipt of a request for an expedited external\n\nreview, the Commissioner immediately shall send a copy of the\n\nrequest to the health carrier.\n\n2. Immediately upon receipt of the request pursuant to\n\nparagraph 1 of this subsection, the health carrier shall determine\n\nwhether the request meets the reviewability requirements set forth\n\nin subsection B of Section 6475.8 of this title. The health carrier\n\nshall immediately notify the Commissioner and the covered person\n\nand, if applicable, the covered person's authorized representative\n\nof its eligibility determination.\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 an 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\nSection 6475.8 of this title notwithstanding a health\n\ncarrier's initial determination that the request is\n\nineligible and require that it be referred for\n\nexternal 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\n5. Upon receipt of the notice that the request meets the\n\nreviewability requirements, the Commissioner immediately shall\n\nassign an independent review organization to conduct the expedited\n\nexternal review from the list of approved independent review\n\norganizations compiled and maintained by the Commissioner pursuant\n\nto Section 6475.12 of this title. The Commissioner shall\n\nimmediately notify the health carrier of the name of the assigned\n\nindependent review organization.\n\n6. In reaching a decision in accordance with subsection E of\n\nthis section, the assigned independent review organization shall not\n\nbe bound by any decisions or conclusions reached during the health\n\ncarrier's utilization review process as set forth in Sections 6551\n\nthrough 6565 of this title or the health carrier's internal\n\ngrievance process.\ne of the assigned\n\nindependent review organization.\n\n6. In reaching a decision in accordance with subsection E of\n\nthis section, the assigned independent review organization shall not\n\nbe bound by any decisions or conclusions reached during the health\n\ncarrier's utilization review process as set forth in Sections 6551\n\nthrough 6565 of this title or the health carrier's internal\n\ngrievance process.\n\nC. Upon receipt of the notice from the Commissioner of the name\n\nof the independent review organization assigned to conduct the\n\nexpedited external review pursuant to paragraph 5 of subsection B of\n\nthis section, the health carrier or its designee utilization review\n\norganization shall provide or transmit all necessary documents and\n\ninformation considered in making the adverse determination or final\n\nadverse determination to the assigned independent review\n\norganization electronically or by telephone or facsimile or any\n\nother available expeditious method.\n\nD. In addition to the documents and information provided or\n\ntransmitted pursuant to subsection C of this section, the assigned\n\nindependent review organization, to the extent the information or\n\ndocuments are available and the independent review organization\n\nconsiders them appropriate, shall consider the following in reaching\n\na decision:\n\n1. The covered person's pertinent 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 evidence-based standards, and may include any other practice\n\nguidelines developed by the federal government, national or\n\nprofessional 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 in making adverse determinations; 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 and\n\ndocuments are available and the clinical reviewer or reviewers\n\nconsider appropriate.\n\nE. 1. As expeditiously as the covered person's medical\n\ncondition or circumstances require, but in no event more than\n\nseventy-two (72) hours after the date of receipt of the request for\n\nan expedited external review that meets the reviewability\n\nrequirements set forth in subsection B of Section 6475.8 of this\n\ntitle, the assigned independent review organization shall:\n\na. make a decision to uphold or reverse the adverse\n\ndetermination or final adverse determination, and\n\nb. notify the covered person, if applicable, the covered\n\nperson's authorized representative, the health\n\ncarrier, and the Commissioner of the decision.\n\n2. If the notice provided pursuant to paragraph 1 of this\n\nsubsection was not in writing, within forty-eight (48) hours after\n\nthe date of providing that notice, the assigned independent review\n\norganization shall:\n\na. provide written confirmation of the decision to the\n\ncovered person, if applicable, the covered person's\n\nauthorized representative, the health carrier, and the\n\nCommissioner, and\n\nb. include the information set forth in paragraph 2 of\n\nsubsection I of Section 6475.8 of this title.\n\n3. Upon receipt of the notice of a decision pursuant to\n\nparagraph 1 of this subsection reversing the adverse determination\n\nor final adverse determination, the health carrier immediately shall\ncable, the covered person's\n\nauthorized representative, the health carrier, and the\n\nCommissioner, and\n\nb. include the information set forth in paragraph 2 of\n\nsubsection I of Section 6475.8 of this title.\n\n3. Upon receipt of the notice of a decision pursuant to\n\nparagraph 1 of this subsection reversing the adverse determination\n\nor final adverse determination, the health carrier immediately shall\n\napprove the coverage that was the subject of the adverse\n\ndetermination or final adverse determination.\n\nF. An expedited external review may not be provided for\n\nretrospective adverse or final adverse determinations.\n\nG. 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":"45fadcc36bcc3811564aedbfb8427e4506c19507b34bd6b416277568ae0a8e8b","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6475.8","next":"us-ok/okla.-stat.-tit.-36-36-650"},"notice":"GroundRules: Original legal text. Not legal advice."}