{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.6","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.6","heading":"Requirements for prior authorizations","body":"A. A contracted entity shall meet all requirements established\n\nby this section pertaining to prior authorizations.\n\nTo the extent a contracted entity uses a third-party utilization\n\nreview entity to administer prior authorizations on its behalf, the\n\nutilization review entity shall comply with the provisions of this\n\nsection applicable to contracted entities.\n\nB. 1. A contracted entity shall make any current prior\n\nauthorization requirements and restrictions, including written\n\nclinical criteria, readily accessible on its website to members and\n\nparticipating providers. Such requirements and restrictions shall\n\nbe described in detail but also in easily understandable language.\n\n2. If a contracted entity intends either to implement a new\n\nprior authorization requirement or restriction or to amend an\n\nexisting requirement or restriction, the contracted entity shall:\n\na. ensure that the new or amended requirement or\n\nrestriction is not implemented until the contracted\n\nentity’s website has been updated to reflect the new\n\nor amended requirement or restriction, and\n\nb. provide participating providers credentialed to\n\nperform the service, and members who have a chronic\n\ncondition and are already receiving the service which\n\nthe prior authorization changes will impact, notice of\n\nthe new or amended requirement or restriction no less\n\nthan sixty (60) days before the requirement or\n\nrestriction is implemented.\n\nC. A contracted entity shall ensure that all adverse\n\ndeterminations are made by a licensed physician or, if appropriate\n\nfor the requested service, a licensed mental health professional.\n\nThe physician or mental health professional shall:\n\n1. Possess a current and valid nonrestricted license in any\n\nUnited States jurisdiction;\n\n2. Have the appropriate training, knowledge, or expertise to\n\napply appropriate clinical guidelines to the health care service\n\nbeing requested; and\n\n3. Make the adverse determination under the clinical direction\n\nof a medical director of the contracted entity who is responsible\n\nfor reviewing health care services to members. Any such medical\n\ndirector shall be a physician licensed in any United States\n\njurisdiction.\n\nD. 1. Not later than January 1, 2027, each contracted entity\n\nshall implement and maintain a Prior Authorization Application\n\nProgramming Interface (API), as described in 45 C.F.R., Part 156.\n\n2. Not later than July 1, 2027, all participating providers\n\nshall have electronic health records or practice management systems\n\nthat are compatible with the API, subject to such exceptions as may\n\nbe authorized by the Oklahoma Health Care Authority Board through\n\nrule.\n\nE. 1. If a contracted entity or the Authority requires prior\n\nauthorization of a health care service, the contracted entity shall\n\nmake a prior authorization or adverse determination in accordance\n\nwith the following time periods:\n\na. for urgent health care services, within seventy-two\n\n(72) hours of obtaining all necessary information to\n\nmake the prior authorization or adverse determination,\n\nb. for non-urgent health care services, within seven (7)\n\ndays of obtaining all necessary information to make\n\nthe prior authorization or adverse determination,\n\nc. for covered prescription drugs, within twenty-four\n, within seventy-two\n\n(72) hours of obtaining all necessary information to\n\nmake the prior authorization or adverse determination,\n\nb. for non-urgent health care services, within seven (7)\n\ndays of obtaining all necessary information to make\n\nthe prior authorization or adverse determination,\n\nc. for covered prescription drugs, within twenty-four\n\n(24) hours of obtaining all necessary information to\n\nmake the prior authorization or adverse determination.\n\nThe contracted entity shall not require prior\n\nauthorization on any covered prescription drug for\n\nwhich the Authority does not require prior\n\nauthorization, and\n\nd. for coverage of biomarker testing, in accordance with\n\nSection 4003 of this title.\n\n2. If a participating provider submits all necessary\n\ninformation through the contracted entity’s authorized prior\n\nauthorization system, and if the contracted entity fails to comply\n\nwith the deadlines specified in this subsection, such health care\n\nservices are deemed authorized.\n\n3. For the purposes of this subsection, “necessary information”\n\nincludes, but is not limited to, the results of any face-to-face\n\nclinical evaluation or second opinion that may be required.\n\nF. 1. If a member needs emergency health care services, the\n\nmember’s contracted entity shall not require prior authorization for\n\npre-hospital transportation, for the provision of emergency health\n\ncare services, or for transfers between facilities as required by\n\nthe federal Emergency Medical Treatment and Labor Act.\n\n2. A contracted entity shall allow a member and the member’s\n\nprovider a minimum of twenty-four (24) hours following an emergency\n\nadmission or provision of emergency health care services for the\n\nmember or provider to notify the contracted entity of the admission\n\nor provision of health care services. If the admission or health\n\ncare service occurs on a holiday or weekend, the contracted entity\n\nshall not require notification until the next business day after the\n\nadmission or provision of the health care services.\n\nG. 1. In the notification to the provider that a prior\n\nauthorization has been approved, the contracted entity shall include\n\nin such notification the duration of the prior authorization or the\n\ndate by which the prior authorization will expire.\n\n2. A contracted entity shall not revoke, limit, condition, or\n\nrestrict a prior authorization if the authorized service is provided\n\nwithin forty-five (45) business days from the date the provider\n\nreceived the prior authorization unless the member was no longer\n\neligible for the service on the date it was provided.\n\n3. On receipt of information documenting a prior authorization\n\nfrom the member or from the member’s provider, a contracted entity\n\nshall honor a prior authorization granted to a member from a\n\nprevious contracted entity for at least the initial sixty (60) days\n\nof a member’s coverage under a new contracted entity. During the\n\ntime period described in this subsection, a contracted entity may\n\nperform its own review to grant a prior authorization or make an\n\nadverse determination.\n\nH. A contracted entity shall provide participating providers\n\nwith the following opportunities for communication during the prior\n\nauthorization process:\n\n1. Make staff available at least eight (8) hours each day\n\nduring normal business hours for inbound telephone calls regarding\n\nprior authorization issues;\n\n2. Allow staff to receive inbound communication regarding prior\n\nauthorization issues after normal business hours; and\n\n3. Provide a participating provider with the opportunity to\n\ndiscuss a prior authorization denial with an appropriate reviewer.\n\nI. A contracted entity shall reimburse a participating provider\n\nat the contracted payment rate for a health care service provided by\n\nthe provider per a prior authorization, subject to any applicable\negarding prior\n\nauthorization issues after normal business hours; and\n\n3. Provide a participating provider with the opportunity to\n\ndiscuss a prior authorization denial with an appropriate reviewer.\n\nI. A contracted entity shall reimburse a participating provider\n\nat the contracted payment rate for a health care service provided by\n\nthe provider per a prior authorization, subject to any applicable\n\nreimbursement requirements provided by Section 4002.12 of this\n\ntitle, unless:\n\n1. The provider knowingly and materially misrepresented the\n\nhealth care service in the prior authorization request with the\n\nspecific intent to deceive and obtain an unlawful payment from a\n\ncontracted entity;\n\n2. The health care service was no longer a covered benefit on\n\nthe day it was provided;\n\n3. The provider was no longer contracted with the member’s\n\ncontracted entity on the date the service was provided;\n\n4. The provider failed to meet the contracted entity’s timely\n\nfiling requirements; or\n\n5. The member was no longer eligible for health care coverage\n\non the date the service was provided.","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":"8166b6c93844fcabe75e1ee9e08c69cc179987e9301fa1244490f3276a26f8aa","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.5","next":"us-ok/okla.-stat.-tit.-56-56-4002.7"},"notice":"GroundRules: Original legal text. Not legal advice."}