§56-4002.2. Definitions.

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

As used in the Ensuring Access to Medicaid Act:

1. “Adverse determination” means a determination by a contracted entity or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered Medicaid benefit has been reviewed and, based upon the information provided, does not meet the contracted entity’s or the Oklahoma Health Care Authority’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated;

2. “Accountable care organization” means a network of physicians, hospitals, and other health care providers that provides coordinated care to Medicaid members;

3. “Claims denial error rate” means the rate of claims denials that are overturned on appeal;

4. “Capitated contract” means a contract between the Oklahoma Health Care Authority and a contracted entity for delivery of services to Medicaid members in which the Authority pays a fixed, per-member-per-month rate based on actuarial calculations;

5. “Children’s Specialty Plan” means a health care plan that covers all Medicaid services other than dental services and is designed to provide care to:

children in foster care,

former foster care children up to twenty-five

years of age,

c. juvenile-justice-involved children,

d. children receiving adoption assistance, and

e. on and after July 1, 2026:

(1)children involved in a Family Centered Services

(FCS)case through the Child Welfare Services

division of the Department of Human Services,

(2)children in the custody of the Department of

Human Services and placed at home under court

supervision,

(3)children who are placed at home in a trial

reunification plan administered by the Department

of Human Services, and

(4)Medicaid enrolled parents and guardians whose

children are in an FCS case, are in trial

reunification, or are in the custody of the

Department of Human Services in foster care or

under court supervision;

6. “Clean claim” means a properly completed billing form with Current Procedural Terminology, 4th Edition or a more recent edition, the Tenth Revision of the International Classification of Diseases coding or a more recent revision, or Healthcare Common Procedure Coding System coding where applicable that contains information specifically required in the Provider Billing and Procedures Manual of the Oklahoma Health Care Authority, as defined in 42 C.F.R., Section 447.45(b);

7. “Clinical criteria” means the written policies, written screening procedures, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and any other criteria or rationale used by a contracted entity to determine the necessity and appropriateness of health care services;

8. “Commercial plan” means an organization or entity that undertakes to provide or arrange for the delivery of health care services to Medicaid members on a prepaid basis and is subject to all applicable federal and state laws and regulations;

9. “Contracted entity” means an organization or entity that enters into or will enter into a capitated contract with the Oklahoma Health Care Authority for the delivery of services specified in the Ensuring Access to Medicaid Act that will assume financial risk, operational accountability, and statewide or regional functionality as defined in the Ensuring Access to Medicaid Act in managing comprehensive health outcomes of Medicaid members. For purposes of the Ensuring Access to Medicaid Act, the term contracted entity includes an accountable care organization, a

provider-led entity, a commercial plan, a dental benefit manager, or any other entity as determined by the Authority;

10. “Dental benefit manager” means an entity that handles claims payment and prior authorizations and coordinates dental care with participating providers and Medicaid members;

11. “Essential community provider” means:

a. a Federally Qualified Health Center,

b. a community mental health center,

c. an Indian Health Care Provider,

d. a rural health clinic,

e. a state-operated mental health hospital,

f. a long-term care hospital serving children (LTCH-C),

g. a teaching hospital owned, jointly owned, or

affiliated with and designated by the University

Hospitals Authority, University Hospitals Trust,

Oklahoma State University Medical Authority, or

Oklahoma State University Medical Trust,

h. a provider employed by or contracted with, or

otherwise a member of the faculty practice plan of:

(1)a public, accredited medical school in this

state, or

(2)a hospital or health care entity directly or

indirectly owned or operated by the University

Hospitals Trust or the Oklahoma State University

Medical Trust,

i. a county department of health or city-county health

department,

j. a comprehensive community addiction recovery center,

k. a hospital licensed by this state including all

hospitals participating in the Supplemental Hospital

Offset Payment Program,

l. a Certified Community Behavioral Health Clinic

(CCBHC),

m. a provider employed by or contracted with a primary

care residency program accredited by the Accreditation

Council for Graduate Medical Education,

n. any additional Medicaid provider as approved by the

Authority if the provider either offers services that

are not available from any other provider within a

reasonable access standard or provides a substantial

share of the total units of a particular service

utilized by Medicaid members within the region during

the last three

(3)years, and the combined capacity of

other service providers in the region is insufficient

to meet the total needs of the Medicaid members,

o. a pharmacy or pharmacist, or

any provider not otherwise mentioned in this paragraph

that meets the definition of “essential community

provider” under 45 C.F.R., Section 156.235;

12. “Governing body” means a group of individuals appointed by the contracted entity who approve policies, operations, profit/loss ratios, executive employment decisions, and who have overall responsibility for the operations of the contracted entity of which they are appointed;

13. “Health care service” means any service provided by a participating provider, or by an individual working for or under the supervision of the participating provider, that relates to the diagnosis, assessment, prevention, treatment, or care of any human illness, disease, injury, or condition. Unless the context clearly indicates otherwise, health care service includes the provision of mental health and substance use disorder services and the provision of durable medical equipment;

14. “Local Oklahoma provider organization” means any state provider association, accountable care organization, Certified Community Behavioral Health Clinic, Federally Qualified Health Center, Native American tribe or tribal association, hospital or health system, academic medical institution, currently practicing licensed provider, or other local Oklahoma provider organization as approved by the Authority;

15. “Material change” includes, but is not limited to, any change in overall business operations such as policy, process, or protocol which affects, or can reasonably be expected to affect, more than five percent (5%) of members or participating providers of the contracted entity;

16. “Medically necessary” means services or supplies provided by a participating provider that are:

a. appropriate for the symptoms and diagnosis or

treatment of a member’s condition, illness, disease,

or injury,

b. in accordance with standards of good medical practice,

c. not primarily for the convenience of the member or the

member’s health care provider, and

d. the most appropriate supply or level of service that

can safely be provided to the member as determined by

the Authority;

17. “Participating provider” means a provider who has a contract with or is employed by a contracted entity to provide services to Medicaid members as authorized by the Ensuring Access to Medicaid Act;

18. “Prior authorization” means the process by which a contracted entity or its designee utilization review entity determines the medical necessity and medical appropriateness of

otherwise covered health care services prior to the rendering of such health care services;

19. “Provider” means a health care or dental provider licensed or certified in this state or a provider that meets the Authority’s provider enrollment criteria to contract with the Authority as a SoonerCare provider;

20. “Provider-led entity” means an organization or entity, a majority of whose governing body is composed of individuals who:

a. have experience serving Medicaid members and:

(1)are licensed in this state as physicians,

physician assistants, or Advanced Practice

Registered Nurses,

(2)at least one board member is a licensed

behavioral health provider, or

(3)are employed by:

(a)a hospital or other medical facility

licensed by this state and operating in this

state, or

(b)an inpatient or outpatient mental health or

substance abuse treatment facility or

program licensed or certified by this state

and operating in this state,

b. represent the providers or facilities described in

subparagraph a of this paragraph including, but not

limited to, individuals who are employed by a

statewide provider association, or

c. are nonclinical administrators of clinical practices

serving Medicaid members;

21. “Provider-owned entity” means an organization or entity, a majority of whose ownership is held by Medicaid providers in this state or is held by an entity that directly or indirectly owns or is under common ownership with Medicaid providers in this state;

22. “Statewide” means all counties of this state including the urban region;

23. “Urban region” means:

a. all counties of this state with a county population of

not less than five hundred thousand (500,000)

according to the latest Federal Decennial Census, and

b. all counties that are contiguous to the counties

described in subparagraph a of this paragraph,

combined into one region; and

24. “Urgent health care service” means, with respect to the application of the time period for making a prior authorization determination under Section 4002.6 of this title, a health care service which, in the opinion of a physician with knowledge of the member’s medical condition:

could seriously jeopardize the life or health of the

member or the ability of the member to regain maximum

function, or

b. in the opinion of a physician with knowledge of the

member’s medical condition, would subject the member

to severe pain that cannot be adequately managed

without the care or treatment that is the subject of

the prior authorization. Added by Laws 2021, c. 542, § 2, eff. Sept. 1, 2021. Amended by Laws 2022, c. 395, § 2, eff. July 1, 2022; Laws 2022, c. 334, § 1, eff. July 1, 2022; Laws 2024, c. 448, § 1, emerg. eff. June 14, 2024; Laws 2025, c. 372, § 1, eff. Nov. 1, 2025. NOTE: Laws 2024, c. 206, § 1 repealed by Laws 2025, c. 372, § 4, emerg. eff. May 26, 2025.