Okla. Admin. Code § 365:10-15-2

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-15-2 - Private review agents

(a) The following persons or entities shall be considered private review agent(s) for purposes of the Hospital and Medical Services Utilization Review Act, Sections 6551 through 6581 of Title 36 of the Oklahoma Statutes:

(1) Any person or entity who performs utilization review on behalf of an employer in this state. The term employer means any person or entity who employs any person in this state. No person or entity who performs utilization review on behalf of an employer in this state shall be exempt from the provisions of the Hospital and Medical Services Utilization Review Act on the basis that the employer is self-insured or participates in an ERISA exempt employee welfare benefit plan or multiple employer welfare arrangement;

(2) Any person or entity who performs utilization review on behalf of a health maintenance organization which has been issued a license pursuant to Sections 6901 through 6936 of Title 36 of the Oklahoma Statutes. However, any such person or entity performing utilization review on behalf of a health maintenance organization so licensed shall be exempt from the provisions of the Hospital and Medical Services Utilization Review Act if, prior to performing utilization review, such person or entity has obtained written documentation from the health maintenance organization that:

(A) the health maintenance organization is federally regulated; and

(B) the health maintenance organization has filed with the Commissioner of Health a plan of utilization review which is carried out by health care professionals and which has established complaint and appellate procedures for claims;

(3) Any person or entity who performs utilization review on behalf a third party providing or administering hospital and medical benefits to citizens of this state, including but not limited to a health insurer, not-for-profit hospital service or medical plan, health insurance service organization, preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state;

(b) Any licensed physician or other licensed health care professional who, pursuant to contract, agreement, or through the receipt or promise of any valid consideration, is consulted during the course of utilization review by a person or entity who is licensed to perform utilization review shall not be considered a private review agent.

(c) A private review agent whose provides utilization review services exclusively pursuant to a contract with the federal or state government concerning patients eligible for hospital and medical services under the Social Security Act is exempt from the certification required for private review agents in the Hospital and Medical Services Utilization Review Act.

(d) A private review agent who conducts in-house utilization review services solely for hospitals, home health agencies, preferred provider organizations, or other managed care entities, clinics, private offices or any other health facility or entity must be certified if the private review agent's review results in the approval or denial of payment for hospital and medical services on a particular case. If such private review agent's in-house utilization review is only of a general nature and does not result in the approval or denial of payment for such services on a case by case basis, no certification is required.

(e) A private review agent who conducts outside utilization review services for an insurance company, not-for-profit hospital service or indemnity plan, or a not-for-profit medical or indemnity plan, shall be certified in compliance with the Hospital and Medical Services Utilization Review Act.

(f) Individual employees of a certified private review agent need not be separately certified.

Okla. Admin. Code § 365:10-15-2

Added at 14 Ok Reg 2957, eff 7-14-97; Amended at 27 Ok Reg 1531, eff 7-14-10