{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6570.53","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6570.53","heading":"Review of appeals — Qualifications of reviewers","body":"A utilization review entity shall ensure that all appeals are\n\nreviewed by a physician, pharmacist, or licensed mental health\n\nprofessional. The physician, pharmacist, or licensed mental health\n\nprofessional 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,\n\npharmacist, or licensed mental health professional who typically\n\nmanages the medical condition or disease, which means that the\n\nphysician either maintains board certification for the same or\n\nsimilar specialty as the medical condition in question or whose\n\ntraining 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, pharmacist, or\n\nlicensed mental health professional to determine if\n\nthe service or procedure is medically necessary or\n\nclinically appropriate,\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, or for appeals coming\n\nfrom a pharmacist, which may be conducted by another licensed\n\npharmacist 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":"5986b085feb5e9e2efe8c593c47381d8471e5a20543e7a119357ba0ef2c73fc2","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6570.52","next":"us-ok/okla.-stat.-tit.-36-36-6570.54"},"notice":"GroundRules: Original legal text. Not legal advice."}