{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6570.4","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6570.4","heading":"Appeals to be reviewed by physician or licensed mental","body":"health professional.\n\nA utilization review entity shall ensure that all appeals are\n\nreviewed by a physician or licensed mental health professional. The\n\nphysician or licensed mental health professional shall:\n\n1. Possess a current and valid unrestricted license in any\n\nUnited States jurisdiction;\n\n2. Be of the same or similar specialty as a physician or\n\nlicensed mental health professional who typically manages the\n\nmedical condition or disease, which means that the physician either\n\nmaintains board certification for the same or similar specialty as\n\nthe medical condition in question or whose training and experience:\n\na. includes treating the condition,\n\nb. includes treating complications that may result from\n\nthe service or procedure, and\n\nc. is sufficient for the physician or licensed mental\n\nhealth professional to determine if the service or\n\nprocedure is medically necessary or clinically\n\nappropriate,\n\nexcept for appeals coming from a licensed mental health\n\nprofessional, which may be conducted by another licensed mental\n\nhealth professional as opposed to a physician;\n\n3. Not have been directly involved in making the adverse\n\ndetermination;\n\n4. Not have any financial interest in the outcome of the\n\nappeal; and\n\n5. Consider all known clinical aspects of the health care\n\nservice under review, including, but not limited to, a review of\n\nthose medical records which are pertinent and relevant to the active\n\ncondition provided to the utilization review entity by the\n\nenrollee's health care provider, or a health care facility, and any\n\npertinent medical literature provided to the utilization review\n\nentity by the health care provider.","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":"121a581e5f882ef758d7fbca5e4df27d8b298094aa1a662c4bf3f0d7cab36109","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6570.3","next":"us-ok/okla.-stat.-tit.-36-36-6570.5"},"notice":"GroundRules: Original legal text. Not legal advice."}