{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.2","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.2","heading":"Definitions","body":"As used in the Ensuring Access to Medicaid Act:\n\n1. “Adverse determination” means a determination by a\n\ncontracted entity or its designee utilization review entity that an\n\nadmission, availability of care, continued stay, or other health\n\ncare service that is a covered Medicaid benefit has been reviewed\n\nand, based upon the information provided, does not meet the\n\ncontracted entity’s or the Oklahoma Health Care Authority’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;\n\n2. “Accountable care organization” means a network of\n\nphysicians, hospitals, and other health care providers that provides\n\ncoordinated care to Medicaid members;\n\n3. “Claims denial error rate” means the rate of claims denials\n\nthat are overturned on appeal;\n\n4. “Capitated contract” means a contract between the Oklahoma\n\nHealth Care Authority and a contracted entity for delivery of\n\nservices to Medicaid members in which the Authority pays a fixed,\n\nper-member-per-month rate based on actuarial calculations;\n\n5. “Children’s Specialty Plan” means a health care plan that\n\ncovers all Medicaid services other than dental services and is\n\ndesigned to provide care to:\n\na. children in foster care,\n\nb. former foster care children up to twenty-five (25)\n\nyears of age,\n\nc. juvenile-justice-involved children,\n\nd. children receiving adoption assistance, and\n\ne. on and after July 1, 2026:\n\n(1) children involved in a Family Centered Services\n\n(FCS) case through the Child Welfare Services\n\ndivision of the Department of Human Services,\n\n(2) children in the custody of the Department of\n\nHuman Services and placed at home under court\n\nsupervision,\n\n(3) children who are placed at home in a trial\n\nreunification plan administered by the Department\n\nof Human Services, and\n\n(4) Medicaid enrolled parents and guardians whose\n\nchildren are in an FCS case, are in trial\n\nreunification, or are in the custody of the\n\nDepartment of Human Services in foster care or\n\nunder court supervision;\n\n6. “Clean claim” means a properly completed billing form with\n\nCurrent Procedural Terminology, 4th Edition or a more recent\n\nedition, the Tenth Revision of the International Classification of\n\nDiseases coding or a more recent revision, or Healthcare Common\n\nProcedure Coding System coding where applicable that contains\n\ninformation specifically required in the Provider Billing and\n\nProcedures Manual of the Oklahoma Health Care Authority, as defined\n\nin 42 C.F.R., Section 447.45(b);\n\n7. “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 a contracted entity to determine\n\nthe necessity and appropriateness of health care services;\n\n8. “Commercial plan” means an organization or entity that\n\nundertakes to provide or arrange for the delivery of health care\n\nservices to Medicaid members on a prepaid basis and is subject to\n\nall applicable federal and state laws and regulations;\n\n9. “Contracted entity” means an organization or entity that\n\nenters into or will enter into a capitated contract with the\n\nOklahoma Health Care Authority for the delivery of services\n\nspecified in the Ensuring Access to Medicaid Act that will assume\n\nfinancial risk, operational accountability, and statewide or\n\nregional functionality as defined in the Ensuring Access to Medicaid\n\nAct in managing comprehensive health outcomes of Medicaid members.\n\nFor purposes of the Ensuring Access to Medicaid Act, the term\n\ncontracted entity includes an accountable care organization, a\n\nprovider-led entity, a commercial plan, a dental benefit manager, or\n\nany other entity as determined by the Authority;\nthe Ensuring Access to Medicaid\n\nAct in managing comprehensive health outcomes of Medicaid members.\n\nFor purposes of the Ensuring Access to Medicaid Act, the term\n\ncontracted entity includes an accountable care organization, a\n\nprovider-led entity, a commercial plan, a dental benefit manager, or\n\nany other entity as determined by the Authority;\n\n10. “Dental benefit manager” means an entity that handles\n\nclaims payment and prior authorizations and coordinates dental care\n\nwith participating providers and Medicaid members;\n\n11. “Essential community provider” means:\n\na. a Federally Qualified Health Center,\n\nb. a community mental health center,\n\nc. an Indian Health Care Provider,\n\nd. a rural health clinic,\n\ne. a state-operated mental health hospital,\n\nf. a long-term care hospital serving children (LTCH-C),\n\ng. a teaching hospital owned, jointly owned, or\n\naffiliated with and designated by the University\n\nHospitals Authority, University Hospitals Trust,\n\nOklahoma State University Medical Authority, or\n\nOklahoma State University Medical Trust,\n\nh. a provider employed by or contracted with, or\n\notherwise a member of the faculty practice plan of:\n\n(1) a public, accredited medical school in this\n\nstate, or\n\n(2) a hospital or health care entity directly or\n\nindirectly owned or operated by the University\n\nHospitals Trust or the Oklahoma State University\n\nMedical Trust,\n\ni. a county department of health or city-county health\n\ndepartment,\n\nj. a comprehensive community addiction recovery center,\n\nk. a hospital licensed by this state including all\n\nhospitals participating in the Supplemental Hospital\n\nOffset Payment Program,\n\nl. a Certified Community Behavioral Health Clinic\n\n(CCBHC),\n\nm. a provider employed by or contracted with a primary\n\ncare residency program accredited by the Accreditation\n\nCouncil for Graduate Medical Education,\n\nn. any additional Medicaid provider as approved by the\n\nAuthority if the provider either offers services that\n\nare not available from any other provider within a\n\nreasonable access standard or provides a substantial\n\nshare of the total units of a particular service\n\nutilized by Medicaid members within the region during\n\nthe last three (3) years, and the combined capacity of\n\nother service providers in the region is insufficient\n\nto meet the total needs of the Medicaid members,\n\no. a pharmacy or pharmacist, or\n\np. any provider not otherwise mentioned in this paragraph\n\nthat meets the definition of “essential community\n\nprovider” under 45 C.F.R., Section 156.235;\n\n12. “Governing body” means a group of individuals appointed by\n\nthe contracted entity who approve policies, operations, profit/loss\n\nratios, executive employment decisions, and who have overall\n\nresponsibility for the operations of the contracted entity of which\n\nthey are appointed;\n\n13. “Health care service” means any service provided by a\n\nparticipating provider, or by an individual working for or under the\n\nsupervision of the participating provider, that relates to the\n\ndiagnosis, assessment, prevention, treatment, or care of any human\n\nillness, disease, injury, or condition. Unless the context clearly\n\nindicates otherwise, health care service includes the provision of\n\nmental health and substance use disorder services and the provision\n\nof durable medical equipment;\n\n14. “Local Oklahoma provider organization” means any state\n\nprovider association, accountable care organization, Certified\n\nCommunity Behavioral Health Clinic, Federally Qualified Health\n\nCenter, Native American tribe or tribal association, hospital or\n\nhealth system, academic medical institution, currently practicing\n\nlicensed provider, or other local Oklahoma provider organization as\n\napproved by the Authority;\n\n15. “Material change” includes, but is not limited to, any\n\nchange in overall business operations such as policy, process, or\nl Health Clinic, Federally Qualified Health\n\nCenter, Native American tribe or tribal association, hospital or\n\nhealth system, academic medical institution, currently practicing\n\nlicensed provider, or other local Oklahoma provider organization as\n\napproved by the Authority;\n\n15. “Material change” includes, but is not limited to, any\n\nchange in overall business operations such as policy, process, or\n\nprotocol which affects, or can reasonably be expected to affect,\n\nmore than five percent (5%) of members or participating providers of\n\nthe contracted entity;\n\n16. “Medically necessary” means services or supplies provided\n\nby a participating provider that are:\n\na. appropriate for the symptoms and diagnosis or\n\ntreatment of a member’s condition, illness, disease,\n\nor injury,\n\nb. in accordance with standards of good medical practice,\n\nc. not primarily for the convenience of the member or the\n\nmember’s health care provider, and\n\nd. the most appropriate supply or level of service that\n\ncan safely be provided to the member as determined by\n\nthe Authority;\n\n17. “Participating provider” means a provider who has a\n\ncontract with or is employed by a contracted entity to provide\n\nservices to Medicaid members as authorized by the Ensuring Access to\n\nMedicaid Act;\n\n18. “Prior authorization” means the process by which a\n\ncontracted entity or its designee utilization review entity\n\ndetermines the medical necessity and medical appropriateness of\n\notherwise covered health care services prior to the rendering of\n\nsuch health care services;\n\n19. “Provider” means a health care or dental provider licensed\n\nor certified in this state or a provider that meets the Authority’s\n\nprovider enrollment criteria to contract with the Authority as a\n\nSoonerCare provider;\n\n20. “Provider-led entity” means an organization or entity, a\n\nmajority of whose governing body is composed of individuals who:\n\na. have experience serving Medicaid members and:\n\n(1) are licensed in this state as physicians,\n\nphysician assistants, or Advanced Practice\n\nRegistered Nurses,\n\n(2) at least one board member is a licensed\n\nbehavioral health provider, or\n\n(3) are employed by:\n\n(a) a hospital or other medical facility\n\nlicensed by this state and operating in this\n\nstate, or\n\n(b) an inpatient or outpatient mental health or\n\nsubstance abuse treatment facility or\n\nprogram licensed or certified by this state\n\nand operating in this state,\n\nb. represent the providers or facilities described in\n\nsubparagraph a of this paragraph including, but not\n\nlimited to, individuals who are employed by a\n\nstatewide provider association, or\n\nc. are nonclinical administrators of clinical practices\n\nserving Medicaid members;\n\n21. “Provider-owned entity” means an organization or entity, a\n\nmajority of whose ownership is held by Medicaid providers in this\n\nstate or is held by an entity that directly or indirectly owns or is\n\nunder common ownership with Medicaid providers in this state;\n\n22. “Statewide” means all counties of this state including the\n\nurban region;\n\n23. “Urban region” means:\n\na. all counties of this state with a county population of\n\nnot less than five hundred thousand (500,000)\n\naccording to the latest Federal Decennial Census, and\n\nb. all counties that are contiguous to the counties\n\ndescribed in subparagraph a of this paragraph,\n\ncombined into one region; and\n\n24. “Urgent health care service” means, with respect to the\n\napplication of the time period for making a prior authorization\n\ndetermination under Section 4002.6 of this title, a health care\n\nservice which, in the opinion of a physician with knowledge of the\n\nmember’s medical condition:\n\na. could seriously jeopardize the life or health of the\n\nmember or the ability of the member to regain maximum\n\nfunction, or\n\nb. in the opinion of a physician with knowledge of the\n\nmember’s medical condition, would subject the member\na health care\n\nservice which, in the opinion of a physician with knowledge of the\n\nmember’s medical condition:\n\na. could seriously jeopardize the life or health of the\n\nmember or the ability of the member to regain maximum\n\nfunction, or\n\nb. in the opinion of a physician with knowledge of the\n\nmember’s medical condition, would subject the member\n\nto severe pain that cannot be adequately managed\n\nwithout the care or treatment that is the subject of\n\nthe prior authorization.","path":["OK Code","Title 56"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os56.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"20698b453ce5a3bba07491b296d68c5f960c4283aba5b589bb20fa063940abf8","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.1a","next":"us-ok/okla.-stat.-tit.-56-56-4002.3a"},"notice":"GroundRules: Original legal text. Not legal advice."}