{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6570.1","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6570.1","heading":"Definitions","body":"As used in this act:\n\n1. \"Adverse determination\" means a determination by a health\n\ncarrier or its designee utilization review entity that an admission,\n\navailability of care, continued stay, or other health care service\n\nthat is a covered benefit has been reviewed and, based upon the\n\ninformation 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 as defined by Section 6475.3 of Title 36 of the Oklahoma\n\nStatutes;\n\n2. \"Chronic condition\" means a condition that lasts one (1)\n\nyear or more and requires ongoing medical attention or limits\n\nactivities of daily living or both;\n\n3. \"Clinical criteria\" means the written policies, written\n\nscreening procedures, determination rules, determination abstracts,\n\nclinical protocols, practice guidelines, medical protocols, and any\n\nother criteria or rationale used by the utilization review entity to\n\ndetermine the necessity and appropriateness of health care services;\n\n4. \"Emergency health care services\", with respect to an\n\nemergency medical condition as defined in 42 U.S.C.A., Section\n\n300gg-111, means:\n\na. a medical screening examination, as required under\n\nSection 1867 of the Social Security Act, 42 U.S.C.,\n\nSection 1395dd, or as would be required under such\n\nsection if such section applied to an independent,\n\nfreestanding emergency department, that is within the\n\ncapability of the emergency department of a hospital\n\nor of an independent, freestanding emergency\n\ndepartment, as applicable, including ancillary\n\nservices routinely available to the emergency\n\ndepartment to evaluate such emergency medical\n\ncondition, and\n\nb. within the capabilities of the staff and facilities\n\navailable at the hospital or the independent,\n\nfreestanding emergency department, as applicable, such\n\nfurther medical examination and treatment as are\n\nrequired under Section 1395dd of the Social Security\n\nAct, or as would be required under such section if\n\nsuch section applied to an independent, freestanding\n\nemergency department, to stabilize the patient,\n\nregardless of the department of the hospital in which\n\nsuch further examination or treatment is furnished, as\n\ndefined by 42 U.S.C.A., Section 300gg-111;\n\n5. \"Emergency Medical Treatment and Active Labor Act\" or\n\n\"EMTALA\" means Section 1867 of the Social Security Act and\n\nassociated regulations;\n\n6. \"Enrollee\" means an individual who is enrolled in a health\n\ncare plan, including covered dependents, as defined by Section\n\n6592.1 of Title 36 of the Oklahoma Statutes;\n\n7. \"Health care provider\" means any person or other entity who\n\nis licensed pursuant to the provisions of Title 59 or Title 63 of\n\nthe Oklahoma Statutes, or pursuant to the definition in Section 1-\n\n1708.1C of Title 63 of the Oklahoma Statutes;\n\n8. \"Health care services\" means any services provided by a\n\nhealth care provider, or by an individual working for or under the\n\nsupervision of a health care provider, that relate to the diagnosis,\n\nassessment, prevention, treatment, or care of any human illness,\n\ndisease, injury, or condition, as defined by paragraph 2 of Section\n\n1-1708.1C of Title 63 of the Oklahoma Statutes.\n\nThe term also includes the provision of mental health and substance\n\nuse disorder services, as defined by Section 6060.10 of Title 36 of\n\nthe Oklahoma Statutes, and the provision of durable medical\n\nequipment. The term does not include the provision, administration,\n\nor prescription of pharmaceutical products or services;\n\n9. \"Licensed mental health professional\" means:\n\na. a psychiatrist who is a diplomate of the American\n\nBoard of Psychiatry and Neurology,\n\nb. a psychiatrist who is a diplomate of the American\n\nOsteopathic Board of Neurology and Psychiatry,\nthe provision of durable medical\n\nequipment. The term does not include the provision, administration,\n\nor prescription of pharmaceutical products or services;\n\n9. \"Licensed mental health professional\" means:\n\na. a psychiatrist who is a diplomate of the American\n\nBoard of Psychiatry and Neurology,\n\nb. a psychiatrist who is a diplomate of the American\n\nOsteopathic Board of Neurology and Psychiatry,\n\nc. a physician licensed pursuant to the Oklahoma\n\nAllopathic Medical and Surgical Licensure and\n\nSupervision Act or the Oklahoma Osteopathic Medicine\n\nAct,\n\nd. a clinical psychologist who is duly licensed to\n\npractice by the State Board of Examiners of\n\nPsychologists,\n\ne. a professional counselor licensed pursuant to the\n\nLicensed Professional Counselors Act,\n\nf. a person licensed as a clinical social worker pursuant\n\nto the provisions of the Social Worker's Licensing\n\nAct,\n\ng. a licensed marital and family therapist as defined in\n\nthe Marital and Family Therapist Licensure Act,\n\nh. a licensed behavioral practitioner as defined in the\n\nLicensed Behavioral Practitioner Act,\n\ni. an advanced practice nurse as defined in the Oklahoma\n\nNursing Practice Act,\n\nj. a physician assistant who is licensed in good standing\n\nin this state, or\n\nk. a licensed alcohol and drug counselor/mental health\n\n(LADC/MH) as defined in the Licensed Alcohol and Drug\n\nCounselors Act;\n\n10. \"Medically necessary\" means services or supplies provided\n\nby a health care provider that are:\n\na. appropriate for the symptoms and diagnosis or\n\ntreatment of the enrollee's condition, illness,\n\ndisease, or injury,\n\nb. in accordance with standards of good medical practice,\n\nc. not primarily for the convenience of the enrollee or\n\nthe enrollee's health care provider, and\n\nd. the most appropriate supply or level of service that\n\ncan safely be provided to the enrollee as defined by\n\nSection 6592 of Title 36 of the Oklahoma Statutes;\n\n11. \"Notice\" means communication delivered either\n\nelectronically or through the United States Postal Service or common\n\ncarrier;\n\n12. \"Physician\" means an allopathic or osteopathic physician\n\nlicensed by the State of Oklahoma or another state to practice\n\nmedicine;\n\n13. \"Prior authorization\" means the process by which\n\nutilization review entities determine the medical necessity and\n\nmedical appropriateness of otherwise covered health care services\n\nprior to the rendering of such health care services. The term shall\n\ninclude \"authorization\", \"pre-certification\", and any other term\n\nthat would be a reliable determination by a health benefit plan.\n\nThe term shall not be construed to include or refer to such\n\nprocesses as they may pertain to pharmaceutical services;\n\n14. \"Urgent health care service\" means a health care service\n\nwith respect to which the application of the time periods for making\n\nan urgent care determination, which, in the opinion of a physician\n\nwith knowledge of the enrollee's medical condition:\n\na. could seriously jeopardize the life or health of the\n\nenrollee or the ability of the enrollee to regain\n\nmaximum function, or\n\nb. in the opinion of a physician with knowledge of the\n\nclaimant's medical condition, would subject the\n\nenrollee to severe pain that cannot be adequately\n\nmanaged without the care or treatment that is the\n\nsubject of the utilization review; and\n\n15. \"Utilization review entity\" means an individual or entity\n\nthat performs prior authorization for a health benefit plan as\n\ndefined by Section 6060.4 of Title 36 of the Oklahoma Statutes, but\n\nshall not include any health plan offered by a contracted entity\n\ndefined in Section 4002.2 of Title 56 of the Oklahoma Statutes that\n\nprovides coverage to members of the state Medicaid program or other\n\ninsurance subject to the Long-Term Care Insurance Act.","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":"37e2f683f600acee97f605b4235bf4cd959e0f84467bbcc5ef7902d831163543","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6565","next":"us-ok/okla.-stat.-tit.-36-36-6570.10"},"notice":"GroundRules: Original legal text. Not legal advice."}