Okla. Admin. Code § 310:657-23-1

Current through Vol. 41, No. 19, June 17, 2024

Section 310:657-23-1 - Conditions for approval

The Commissioner shall issue or renew a certificate when the Commissioner finds that the Plan meets the requirements of the Act and OAC 310:657.

(1) Necessary medical and health services shall be provided by the Plan as guaranteed in the Plan's contracts with insurers and insureds and in the provider directory.

(A) These services shall be provided without bias for, or against, any type of provider.

(B) The Commissioner shall review services available considering employee population and characteristics, and locations and hours of providers.

(C) The Plan may offer necessary medical and health services directly, or may arrange services through contracts or arrangements with providers, or may both offer and arrange services.

(2) All providers shall practice under licensing, certification or credentialing requirements of applicable laws, rules and professional standards.

(3) Medical and health services shall be available within the Plan's service area, considering the geographic location of the Plan and its providers, hours of operation, and population density.

(4) The Plan shall appoint a medical director qualified under the licensing or credentialing requirements of Oklahoma.

(5) The Plan shall maintain or arrange quality assurance, peer review, utilization review, dispute and grievance resolution, case management, and workplace health and safety consulting services.

(A) The Commissioner may consider the Plan's compliance with the standards of a recognized voluntary reviewing entity. Before accepting findings from another entity, the Commissioner shall affirm that the standards in use by the entity meet or exceed the standards set by the Commissioner.

(B) The Commissioner may approve a reasonable phase-in of these systems, based on the length of time the Plan has operated and the number of employees.

(C) The Commissioner shall consider a license, certificate or approval granted by an agency of the State of Oklahoma or the federal government.

(6) The persons responsible for the Plan have knowledge, skills and experience to operate the Plan.

(7) The Plan shall demonstrate financial responsibility and may reasonably be expected to meet its obligations to injured workers. The Commissioner shall consider the resources of the Plan's owner and may also consider the following:

(A) The financial soundness of any arrangements for paying providers, the accounting methods to control any funds paid to the Plan for providers, and the schedule of charges;

(B) Working capital; or

(C) Any agreement with providers for services.

Okla. Admin. Code § 310:657-23-1

Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff 6-25-06