{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6907","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6907","heading":"Reasonable standards of quality of care - Quality","body":"assurance plan and activities - Record of proceedings - Patient\n\nrecord system - Medical policy - Credentialing and recredentialing\n\nof health care providers - Termination or nonrenewal of contracts -\n\nEmergency services.\n\nA. Every health maintenance organization shall establish\n\nprocedures that ensure that health care services provided to\n\nenrollees shall be rendered under reasonable standards of quality of\n\ncare consistent with prevailing professionally recognized standards\n\nof medical practice. The procedures shall include mechanisms to\n\nassure availability, accessibility and continuity of care.\n\nB. The health maintenance organization shall have an ongoing\n\ninternal quality assurance program to monitor and evaluate its\n\nhealth care services, including primary and specialist physician\n\nservices and ancillary and preventive health care services across\n\nall institutional and noninstitutional settings. The program shall\n\ninclude, but need not be limited to, the following:\n\n1. A written statement of goals and objectives that emphasizes\n\nimproved health status in evaluating the quality of care rendered to\n\nenrollees;\n\n2. A written quality assurance plan that describes the\n\nfollowing:\n\na. the health maintenance organization's scope and\n\npurpose in quality assurance,\n\nb. the organizational structure responsible for quality\n\nassurance activities,\n\nc. contractual arrangements, where appropriate, for\n\ndelegation of quality assurance activities,\n\nd. confidentiality policies and procedures,\n\ne. a system of ongoing evaluation activities,\n\nf. a system of focused evaluation activities,\n\ng. a system for credentialing and recredentialing\n\nproviders, and performing peer review activities, and\n\nh. duties and responsibilities of the designated\n\nphysician responsible for the quality assurance\n\nactivities;\n\n3. A written statement describing the system of ongoing quality\n\nassurance activities including:\n\na. problem assessment, identification, selection and\n\nstudy,\n\nb. corrective action, monitoring, evaluation and\n\nreassessment, and\n\nc. interpretation and analysis of patterns of care\n\nrendered to individual patients by individual\n\nproviders;\n\n4. A written statement describing the system of focused quality\n\nassurance activities based on representative samples of the enrolled\n\npopulation that identifies method of topic selection, study, data\n\ncollection, analysis, interpretation and report format; and\n\n5. Written plans for taking appropriate corrective action\n\nwhenever, as determined by the quality assurance program,\n\ninappropriate or substandard services have been provided or services\n\nthat should have been furnished have not been provided.\n\nC. The organization shall record proceedings of formal quality\n\nassurance program activities and maintain documentation in a\n\nconfidential manner. Quality assurance program minutes shall be\n\navailable to the Insurance Commissioner.\n\nD. The organization shall ensure the use and maintenance of an\n\nadequate patient record system which will facilitate documentation\n\nand retrieval of clinical information for the purpose of the health\n\nmaintenance organization's evaluating continuity and coordination of\n\npatient care and assessing the quality of health and medical care\n\nprovided to enrollees.\n\nE. Enrollee clinical records shall be available to the\n\nInsurance Commissioner or an authorized designee for examination and\n\nreview to ascertain compliance with this section, or as deemed\n\nnecessary by the Insurance Commissioner.\n\nF. The organization shall establish a mechanism for periodic\n\nreporting of quality assurance program activities to the governing\n\nbody, providers and appropriate organization staff.\n\nG. The organization shall be required to establish a mechanism\n\nunder which physicians participating in the plan may provide input\n\ninto the plan's medical policy including, but not limited to,\n\ncoverage of new technology and procedures, utilization review\nechanism for periodic\n\nreporting of quality assurance program activities to the governing\n\nbody, providers and appropriate organization staff.\n\nG. The organization shall be required to establish a mechanism\n\nunder which physicians participating in the plan may provide input\n\ninto the plan's medical policy including, but not limited to,\n\ncoverage of new technology and procedures, utilization review\n\ncriteria and procedures, quality, credentialing and recredentialing\n\ncriteria, and medical management procedures.\n\nH. As used in this section \"credentialing\" or\n\n\"recredentialing\", as applied to physicians and other health care\n\nproviders, means the process of accessing and validating the\n\nqualifications of such persons to provide health care services to\n\nthe beneficiaries of a health maintenance organization.\n\nCredentialing or recredentialing may include, but need not be\n\nlimited to, an evaluation of licensure status, education, training,\n\nexperience, competence and professional judgment. Credentialing or\n\nrecredentialing is a prerequisite to the final decision of a health\n\nmaintenance organization to permit initial or continued\n\nparticipation by a physician or other health care provider.\n\n1. Physician credentialing and recredentialing shall be based\n\non criteria as provided in the uniform credentialing application\n\nrequired by Section 1-106.2 of Title 63 of the Oklahoma Statutes,\n\nwith input from physicians and other health care providers.\n\n2. Organizations shall make information on credentialing and\n\nrecredentialing criteria available to physician applicants and other\n\nhealth care providers, participating physicians, and other\n\nparticipating health care providers and shall provide applicants\n\nwith a checklist of materials required in the application process.\n\n3. When economic considerations are part of the credentialing\n\nand recredentialing decision, objective criteria shall be used and\n\nshall be available to physician applicants and participating\n\nphysicians. When graduate medical education is a consideration in\n\nthe credentialing and recredentialing process, equal recognition\n\nshall be given to training programs accredited by the Accrediting\n\nCouncil on Graduate Medical Education and by the American\n\nOsteopathic Association. When graduate medical education is\n\nconsidered for optometric physicians, consideration shall be given\n\nfor educational accreditation by the Council on Optometric\n\nEducation.\n\n4. Physicians or other health care providers under\n\nconsideration to provide health care services under a managed care\n\nplan in this state shall apply for credentialing and recredentialing\n\non the uniform credentialing application and provide the\n\ndocumentation as outlined by the plan's checklist of materials\n\nrequired in the application process.\n\n5. A health maintenance organization (HMO) shall determine\n\nwhether a credentialing or recredentialing application is complete.\n\nIf an application is determined to be incomplete, the plan shall\n\nnotify the applicant in writing within ten (10) calendar days of\n\nreceipt of the application. The written notice shall specify the\n\nportion of the application that is causing a delay in processing and\n\nexplain any additional information or corrections needed.\n\n6. In reviewing the application, the health maintenance\n\norganization (HMO) shall evaluate each application according to the\n\nplan's checklist of materials required in the application process.\n\n7. When an application is deemed complete, the HMO shall\n\ninitiate requests for primary source verification and malpractice\n\nhistory within seven (7) calendar days.\n\n8. A malpractice carrier shall have twenty-one (21) calendar\n\ndays within which to respond after receipt of an inquiry from a\n\nhealth maintenance organization (HMO). Any malpractice carrier that\n\nfails to respond to an inquiry within the allotted time frame may be\ned complete, the HMO shall\n\ninitiate requests for primary source verification and malpractice\n\nhistory within seven (7) calendar days.\n\n8. A malpractice carrier shall have twenty-one (21) calendar\n\ndays within which to respond after receipt of an inquiry from a\n\nhealth maintenance organization (HMO). Any malpractice carrier that\n\nfails to respond to an inquiry within the allotted time frame may be\n\nassessed an administrative penalty by the Insurance Commissioner.\n\n9. Upon receipt of primary source verification and malpractice\n\nhistory by the HMO, the HMO shall determine if the application is a\n\nclean application. If the application is deemed clean, the HMO\n\nshall have forty-five (45) calendar days within which to credential\n\nor recredential a physician or other health care provider. As used\n\nin this paragraph, \"clean application\" means an application that has\n\nno defect, misstatement of facts, improprieties, including a lack of\n\nany required substantiating documentation, or particular\n\ncircumstance requiring special treatment that impedes prompt\n\ncredentialing or recredentialing.\n\n10. If a health maintenance organization is unable to\n\ncredential or recredential a physician or other health care provider\n\ndue to an application's not being clean, the HMO may extend the\n\ncredentialing or recredentialing process for sixty (60) calendar\n\ndays. At the end of sixty (60) calendar days, if the HMO is\n\nawaiting documentation to complete the application, the physician or\n\nother health care provider shall be notified of the delay by\n\ncertified mail. The physician or other health care provider may\n\nextend the sixty-day period upon written notice to the HMO within\n\nten (10) calendar days; otherwise the application shall be deemed\n\nwithdrawn.\n\n11. In no event shall the entire credentialing or\n\nrecredentialing process exceed one hundred eighty (180) calendar\n\ndays.\n\n12. A health maintenance organization shall be prohibited from\n\nsolely basing a denial of an application for credentialing or\n\nrecredentialing on the lack of board certification or board\n\neligibility and from adding new requirements solely for the purpose\n\nof delaying an application.\n\n13. Any HMO that violates the provisions of this subsection may\n\nbe assessed an administrative penalty by the Insurance Commissioner.\n\nI. Health maintenance organizations shall not discriminate\n\nagainst enrollees with expensive medical conditions by excluding\n\npractitioners with practices containing a substantial number of\n\nthese patients.\n\nJ. Health maintenance organizations shall, upon request,\n\nprovide to a physician whose contract is terminated or not renewed\n\nfor cause the reasons for termination or nonrenewal. Health\n\nmaintenance organizations shall not contractually prohibit such\n\nrequests.\n\nK. No HMO shall engage in the practice of medicine or any other\n\nprofession except as provided by law nor shall an HMO include any\n\nprovision in a provider contract that precludes or discourages a\n\nhealth maintenance organization's providers from:\n\n1. Informing a patient of the care the patient requires,\n\nincluding treatments or services not provided or reimbursed under\n\nthe patient's HMO; or\n\n2. Advocating on behalf of a patient before the HMO.\n\nL. Decisions by a health maintenance organization to authorize\n\nor deny coverage for an emergency service shall be based on the\n\npatient presenting symptoms arising from any injury, illness, or\n\ncondition manifesting itself by acute symptoms of sufficient\n\nseverity, including severe pain, such that a reasonable and prudent\n\nlayperson could expect the absence of medical attention to result in\n\nserious:\n\n1. Jeopardy to the health of the patient;\n\n2. Impairment of bodily function; or\n\n3. Dysfunction of any bodily organ or part.\n\nM. Health maintenance organizations shall not deny an otherwise\n\ncovered emergency service based solely upon lack of notification to\n\nthe HMO.\nng severe pain, such that a reasonable and prudent\n\nlayperson could expect the absence of medical attention to result in\n\nserious:\n\n1. Jeopardy to the health of the patient;\n\n2. Impairment of bodily function; or\n\n3. Dysfunction of any bodily organ or part.\n\nM. Health maintenance organizations shall not deny an otherwise\n\ncovered emergency service based solely upon lack of notification to\n\nthe HMO.\n\nN. Health maintenance organizations shall compensate a provider\n\nfor patient screening, evaluation, and examination services that are\n\nreasonably calculated to assist the provider in determining whether\n\nthe condition of the patient requires emergency service. If the\n\nprovider determines that the patient does not require emergency\n\nservice, coverage for services rendered subsequent to that\n\ndetermination shall be governed by the HMO contract.\n\nO. If within a period of thirty (30) minutes after receiving a\n\nrequest from a hospital emergency department for a specialty\n\nconsultation, a health maintenance organization fails to identify an\n\nappropriate specialist who is available and willing to assume the\n\ncare of the enrollee, the emergency department may arrange for\n\nemergency services by an appropriate specialist that are medically\n\nnecessary to attain stabilization of an emergency medical condition,\n\nand the HMO shall not deny coverage for the services due to lack of\n\nprior authorization.\n\nP. The reimbursement policies and patient transfer requirements\n\nof a health maintenance organization shall not, directly or\n\nindirectly, require a hospital emergency department or provider to\n\nviolate the federal Emergency Medical Treatment and Active Labor\n\nAct. If a member of an HMO is transferred from a hospital emergency\n\ndepartment facility to another medical facility, the HMO shall\n\nreimburse the transferring facility and provider for services\n\nprovided to attain stabilization of the emergency medical condition\n\nof the member in accordance with the federal Emergency Medical\n\nTreatment and Active Labor 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":"45cf33d14cf12006945e39144420d8bd16703fd350857e47802f94062bbbd5ae","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6906","next":"us-ok/okla.-stat.-tit.-36-36-6908"},"notice":"GroundRules: Original legal text. Not legal advice."}