{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.7","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.7","heading":"Requirements for processing and adjudicating claims","body":"A. The Oklahoma Health Care Authority shall establish\n\nrequirements for fair processing and adjudication of claims that\n\nensure prompt reimbursement of providers by contracted entities. A\n\ncontracted entity shall comply with all such requirements.\n\nB. A contracted entity shall process a clean claim in the time\n\nframe provided by Section 1219 of Title 36 of the Oklahoma Statutes\n\nand no less than ninety percent (90%) of all clean claims shall be\n\npaid within fourteen (14) days of submission to the contracted\n\nentity. A clean claim that is not processed within the time frame\n\nprovided by Section 1219 of Title 36 of the Oklahoma Statutes shall\n\nbear simple interest at the monthly rate of one and one-half percent\n\n(1.5%) payable to the provider. A claim filed by a provider within\n\nsix (6) months of the date the item or service was furnished to a\n\nmember shall be considered timely. If a claim meets the definition\n\nof a clean claim, the contracted entity shall not request medical\n\nrecords of the member prior to paying the claim. Once a claim has\n\nbeen paid, the contracted entity may request medical records if\n\nadditional documentation is needed to review the claim for medical\n\nnecessity.\n\nC. In the case of a denial of a claim including, but not\n\nlimited to, a denial on the basis of the level of emergency care\n\nindicated on the claim, or in the case of a downcoded claim, the\n\ncontracted entity shall establish a process by which the provider\n\nmay identify and provide such additional information as may be\n\nnecessary to substantiate the claim. Any such claim denial or\n\ndowncode shall include the following:\n\n1. A detailed explanation of the basis for the denial; and\n\n2. A detailed description of the additional information\n\nnecessary to substantiate the claim.\n\nD. Postpayment audits by a contracted entity shall be subject\n\nto the following requirements:\n\n1. Subject to paragraph 2 of this subsection, insofar as a\n\ncontracted entity conducts postpayment audits, the contracted entity\n\nshall employ the postpayment audit process determined by the\n\nAuthority;\n\n2. The Authority shall establish a limit on the percentage of\n\nclaims with respect to which postpayment audits may be conducted by\n\na contracted entity for health care items and services furnished by\n\na provider in a plan year; and\n\n3. The Authority shall provide for the imposition of financial\n\npenalties under such contract in the case of any contracted entity\n\nwith respect to which the Authority determines has a claims denial\n\nerror rate of greater than five percent (5%). The Authority shall\n\nestablish the amount of financial penalties and the time frame under\n\nwhich such penalties shall be imposed on contracted entities under\n\nthis paragraph, in no case less than annually.\n\nE. A contracted entity may only apply readmission penalties\n\npursuant to rules promulgated by the Oklahoma Health Care Authority\n\nBoard. The Board shall promulgate rules establishing a program to\n\nreduce potentially preventable readmissions. The program shall use\n\na nationally recognized tool, establish a base measurement year and\n\na performance year, and provide for risk-adjustment based on the\n\npopulation of the state Medicaid program covered by the contracted\n\nentities.","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":"2ab51d5ac4d86310d8eff3c494162c13343ac4d96056abeee6cfcc1426154d78","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.6","next":"us-ok/okla.-stat.-tit.-56-56-4002.8"},"notice":"GroundRules: Original legal text. Not legal advice."}