§36-6475.5. External review.
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A. 1. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to Section 6475.8, 6475.9, or 6475.10 of this title and include the appropriate statements and information set forth in subsection B of this section at the same time the health carrier sends written notice of:
a. an adverse determination upon completion of the health
carrier's utilization review process set forth in
Sections 6551 through 6565 of this title, and
b. a final adverse determination.
2. As part of the written notice required under paragraph 1 of this subsection, a health carrier shall include the following, or substantially equivalent, language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed
by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Oklahoma Insurance Department."
3. The Insurance Commissioner may promulgate any necessary rule providing for the form and content of the notice required under this section.
B. 1. The health carrier shall include in the notice required under subsection A of this section:
a. for a notice related to an adverse determination, a
statement informing the covered person that:
(1)if the covered person has a medical condition
where the time frame for completion of an
expedited review of a grievance involving an
adverse determination would seriously jeopardize
the life or health of the covered person or would
jeopardize the covered person's ability to regain
maximum function, the covered person or the
covered person's authorized representative may
file a request for an expedited external review
to be conducted pursuant to Section 6475.10 of
this title, or Section 6475.11 of this title if
the adverse determination involves a denial of
coverage based on a determination that the
recommended or requested health care service or
treatment is experimental or investigational and
the covered person's treating physician certifies
in writing that the recommended or requested
health care service or treatment that is the
subject of the adverse determination would be
significantly less effective if not promptly
initiated, at the same time the covered person or
the covered person's authorized representative
files a request for an expedited review of a
grievance involving an adverse determination, but
that the independent review organization assigned
to conduct the expedited external review will
determine whether the covered person shall be
required to complete the expedited review of the
grievance prior to conducting the expedited
external review, and
(2)the covered person or the covered person's
authorized representative may file a grievance
under the health carrier's internal grievance
process, but if the health carrier has not issued
a written decision to the covered person or the
covered person's authorized representative within
thirty
(30)days following the date the covered
person or the covered person's authorized
representative files the grievance with the
health carrier and the covered person or the
covered person's authorized representative has
not requested or agreed to a delay, the covered
person or the covered person's authorized
representative may file a request for external
review pursuant to Section 6475.6 of this title
and shall be considered to have exhausted the
health carrier's internal grievance process for
purposes of Section 6475.7 of this title, and
b. for a notice related to a final adverse determination,
a statement informing the covered person that:
(1)if the covered person has a medical condition
where the time frame for completion of a standard
external review pursuant to Section 6475.8 of
this title would seriously jeopardize the life or
health of the covered person or would jeopardize
the covered person's ability to regain maximum
function, the covered person or the covered
person's authorized representative may file a
request for an expedited external review pursuant
to Section 6475.9 of this title, or
(2)if the final adverse determination concerns:
(a)an admission, availability of care,
continued stay or health care service for
which the covered person received emergency
services, but has not been discharged from a
facility, the covered person or the covered
person's authorized representative may
request an expedited external review
pursuant to Section 6475.9 of this title, or
(b)a denial of coverage based on a
determination that the recommended or
requested health care service or treatment
is experimental or investigational, the
covered person or the covered person's
authorized representative may file a request
for a standard external review to be
conducted pursuant to Section 6475.10 of
this title or if the covered person's
treating physician certifies in writing that
the recommended or requested health care
service or treatment that is the subject of
the request would be significantly less
effective if not promptly initiated, the
covered person or the covered person's
authorized representative may request an
expedited external review to be conducted
under Section 6475.10 of this title.
2. In addition to the information to be provided pursuant to paragraph 1 of this subsection, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to Section 6475.17 of this title, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review.
3. As part of any forms provided under paragraph 2 of this subsection, the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 CFR, Section 164.508, by which the covered person, for purposes of conducting an external review under this act, authorizes the health carrier and the covered person's treating health care provider to disclose protected health information including medical records, concerning the covered person that are pertinent to the external review. Added by Laws 2011, c. 278, § 39. Amended by Laws 2011, c. 360, § 29; Laws 2022, c. 154, § 12, eff. Nov. 1, 2022.