{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.5","heading":"Contracted entity responsibilities — Certificate of","body":"authority required.\n\nA. A contracted entity shall be responsible for all\n\nadministrative functions for members enrolled in its plan including,\n\nbut not limited to, claims processing, authorization of health\n\nservices, care and case management, grievances and appeals, and\n\nother necessary administrative services.\n\nB. Prior to the execution of a contract between a contracted\n\nentity and the Oklahoma Health Care Authority, the contracted entity\n\nshall obtain the appropriate certificate of authority issued by the\n\nInsurance Department.\n\n1. A contracted entity shall obtain a certificate of authority\n\nissued by the Insurance Department to operate as a health\n\nmaintenance organization when the contracted services to be\n\ndelivered include physical health services, behavioral health\n\nservices, and prescription drug services.\n\n2. A contracted entity shall obtain a certificate of authority\n\nissued by the Insurance Department to operate as an accident and\n\nhealth insurer or as a prepaid dental plan organization when the\n\ncontracted services to be delivered include dental services.\n\nC. 1. To ensure providers have a voice in the direction and\n\noperation of the contracted entities selected by the Oklahoma Health\n\nCare Authority under Section 4002.3b of this title, each contracted\n\nentity shall have a shared governance structure that includes:\n\na. representatives of local Oklahoma provider\n\norganizations who are Medicaid providers,\n\nb. essential community providers, and\n\nc. a representative from a teaching hospital owned,\n\njointly owned, or affiliated with and designated by\n\nthe University Hospitals Authority, University\n\nHospitals Trust, Oklahoma State University Medical\n\nAuthority, or Oklahoma State University Medical Trust.\n\n2. No less than one-third (1/3) of the contracted entity's\n\nlocal governing body shall be comprised of representatives of local\n\nOklahoma provider organizations.\n\n3. No less than two members of the contracted entity's clinical\n\nand quality committees shall be representatives of local Oklahoma\n\nprovider organizations, and the committees shall be chaired or co-\n\nchaired by a representative of a local Oklahoma provider\n\norganization.\n\nD. A contracted entity shall promptly notify the Authority of\n\nall material changes affecting the delivery of care or the\n\nadministration of its program.\n\nE. A contracted entity shall have a medical loss ratio that\n\nmeets the standards provided by 42 C.F.R., Section 438.8.\n\nF. A contracted entity shall provide patient data to a provider\n\nupon request to the extent allowed under federal or state laws,\n\nrules or regulations including, but not limited to, the Health\n\nInsurance Portability and Accountability Act of 1996.\n\nG. A contracted entity or a subcontractor of a contracted\n\nentity shall not enforce a policy or contract term with a provider\n\nthat requires the provider to contract for all products that are\n\ncurrently offered or that may be offered in the future by the\n\ncontracted entity or subcontractor.\n\nH. Nothing in this act or in a contract between the Authority\n\nand a contracted entity shall prohibit the contracted entity from\n\ncontracting with a statewide or regional accountable care\n\norganization.\n\nI. Nothing in this act, in a contract between the Authority and\n\na contracted entity, or in a contract between a contracted entity\n\nand a provider shall prohibit any provider from contracting with\n\nmore than one contracted entity.\n\nJ. A contracted entity shall not withhold, fail to offer, or\n\nmake impracticable a contract with a provider on the basis of\n\nindependent practice or lack of hospital system affiliation.\n\nK. All contracted entities shall:\n\n1. Use the same drug formulary, which shall be established by\n\nthe Authority; and\n\n2. Ensure broad access to pharmacies including, but not limited\n\nto, pharmacies contracted with covered entities under Section 340B\n\nof the Public Health Service Act. Such access shall, at a minimum,\nder on the basis of\n\nindependent practice or lack of hospital system affiliation.\n\nK. All contracted entities shall:\n\n1. Use the same drug formulary, which shall be established by\n\nthe Authority; and\n\n2. Ensure broad access to pharmacies including, but not limited\n\nto, pharmacies contracted with covered entities under Section 340B\n\nof the Public Health Service Act. Such access shall, at a minimum,\n\nmeet the requirements of the Patient's Right to Pharmacy Choice Act,\n\nSection 6958 et seq. of Title 36 of the Oklahoma Statutes.\n\nL. Each contracted entity and each participating provider shall\n\nsubmit data through the state-designated entity for health\n\ninformation exchange to ensure effective systems and connectivity to\n\nsupport clinical coordination of care, the exchange of information,\n\nand the availability of data to the Authority to manage the state\n\nMedicaid program.","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":"18456ac2f649bc0468ca9c476dc7a12500360b02d8a49f3bbb3ceed54058f2e3","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.4a","next":"us-ok/okla.-stat.-tit.-56-56-4002.6"},"notice":"GroundRules: Original legal text. Not legal advice."}