{"data":{"id":"us-ok/okla.-stat.-tit.-56-56-4002.8","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 56, § 56-4002.8","heading":"Uniform procedures for review and appeal for adverse","body":"determinations.\n\nA. A contracted entity shall utilize uniform procedures\n\nestablished by the Authority under subsection B of this section for\n\nthe review and appeal of any adverse determination by the contracted\n\nentity sought by any member or provider adversely affected by such\n\ndetermination.\n\nB. The Authority shall develop procedures for members or\n\nproviders to seek review by the contracted entity of any adverse\n\ndetermination made by the contracted entity.\n\nC. A provider shall have six (6) months from the receipt of a\n\nclaim denial to file an appeal.\n\nD. A contracted entity shall ensure that all appeals of adverse\n\ndeterminations made by the contracted entity are reviewed by a\n\nlicensed physician or, if appropriate for the requested service, a\n\nlicensed mental health professional. The contracted entity shall\n\nnot use any automated claim review software or other automated\n\nfunctionality for such appeals.\n\nE. The physician or mental health professional who reviews the\n\nappeal shall:\n\n1. Possess a current and valid unrestricted license in any\n\nUnited States jurisdiction;\n\n2. Be of the same or similar specialty as a physician or mental\n\nhealth professional who typically manages the medical condition or\n\ndisease. This requirement shall be considered met:\n\na. for a physician, if:\n\n(1) the physician maintains board certification for\n\nthe same or similar specialty as the medical\n\ncondition in question, or\n\n(2) the physician’s training and experience:\n\n(a) includes treatment of the condition,\n\n(b) includes treatment of complications that may\n\nresult from the service or procedure, and\n\n(c) is sufficient for the physician to determine\n\nif the service or procedure is medically\n\nnecessary or clinically appropriate, or\n\nb. for a mental health professional, if the mental health\n\nprofessional’s training and experience:\n\n(1) includes treatment of the condition, and\n\n(2) is sufficient for the mental health professional\n\nto determine if the service is medically\n\nnecessary or clinically appropriate;\n\n3. Not have been directly involved in making the adverse\n\ndetermination;\n\n4. Not have any financial interest in the outcome of the\n\nappeal; and\n\n5. Consider all known clinical aspects of the health care\n\nservice under review including, but not limited to, a review of any\n\nmedical records pertinent to the active condition that are provided\n\nto the contracted entity by the member’s provider, or a health care\n\nfacility, and any pertinent medical literature provided to the\n\ncontracted entity by the provider.\n\nF. Upon receipt of notice from the contracted entity that the\n\nadverse determination has been upheld on appeal, the member or\n\nprovider may request a fair hearing from the Authority. The\n\nAuthority shall develop procedures for fair hearings in accordance\n\nwith 42 C.F.R., Part 431.","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":"b7a6e5fed7b2d18834af53ef99d1e7a2a210c1e2c703037bd0d98d3fe9806cc6","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-56-56-4002.7","next":"us-ok/okla.-stat.-tit.-56-56-4003"},"notice":"GroundRules: Original legal text. Not legal advice."}