§56-4003. Biomarker testing coverage.

303 words·~1 min read·/ok/title-56-poor-persons/56-4003

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

A. As used in this section:

1. "Biomarker", "biomarker testing", "consensus statement", and "nationally recognized clinical practice guidelines" shall have the same meaning as provided by Section 1 of this act; and

2. "Contracted entity" shall have the same meaning as provided by Section 4002.2 of Title 56 of the Oklahoma Statutes.

B. The state Medicaid program shall cover biomarker testing in accordance with the requirements provided by this section.

C. Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a member’s disease or condition when the test is supported by medical and scientific evidence, including, but not limited to:

1. Labeled indications for a United States Food and Drug Administration (FDA)-approved or -cleared test;

2. Indicated tests for an FDA-approved drug;

3. Warnings and precautions on FDA-approved drug labels;

4. Centers for Medicare and Medicaid Services

(CMS)national coverage determinations or Medicare Administrative Contractor

(MAC)local coverage determinations; or

5. Nationally recognized clinical practice guidelines and consensus statements.

D. Contracted entities under the state Medicaid program shall provide biomarker testing at the same scope, duration, and frequency as the Medicaid program otherwise provides to members.

E. If prior authorization is required for biomarker testing, the contracted entity shall approve or deny a prior authorization request and notify the member, the member’s provider, and any entity requesting authorization of the service within seventy-two

(72)hours for non-urgent requests or within twenty-four

(24)hours for urgent requests.

F. The member and the member’s provider shall have access to clear, readily accessible, and convenient processes to request an exception to a coverage policy for biomarker testing of the state Medicaid program. The process shall be made readily accessible to all participating providers and members online. Added by Laws 2023, c. 331, § 3, eff. Jan. 1, 2024.