Okla. Stat. tit. 36, § 36-4405.1

of physicians and other health care providers.

A. As used in this section:

1. a. “Health benefit plan” or “plan” means:

(1) group hospital or medical insurance coverages,

(2) not-for-profit hospital or medical service or

indemnity plans,

(3) prepaid health plans,

(4) health maintenance organizations,

(5) preferred provider plans,

(6) multiple employer welfare arrangements (MEWA), or

(7) employer self-insured plans that are not exempt

pursuant to the federal Employee Retirement

Income Security Act of 1974 (ERISA) provisions,

and

b. the term health benefit plan shall not include:

(1) individual plans,

(2) plans that only provide coverage for a specified

disease, accidental death, or dismemberment for

wages or payments in lieu of wages for a period

during which an employee is absent from work

because of sickness or injury or as a supplement

to liability insurance,

(3) Medicare supplemental policies as defined in

Section 1882(g)(1) of the federal Social Security

Act (42 U.S.C., Section 1395ss),

(4) workers’ compensation insurance coverage,

(5) medical payment insurance issued as a part of a

motor vehicle insurance policy, or

(6) long-term care policies, including nursing home

fixed indemnity policies, unless the Insurance

Commissioner determines that the policy provides

comprehensive benefit coverage sufficient to meet

the definition of a health benefit plan; and

2. “Credentialing” or “recredentialing”, as applied to

physicians and other health care providers, means the process of

accessing and validating the qualifications of such persons to

provide health care services to the beneficiaries of a health

benefit plan. Credentialing or recredentialing may include, but is

not limited to, an evaluation of licensure status, education,

training, experience, competence and professional judgment.

Oklahoma Statutes - Title 36. Insurance Page 952

Credentialing or recredentialing is a prerequisite to the final

decision of a health benefit plan to permit initial or continued

participation by a physician or other health care provider.

B. 1. Any health benefit plan that is offered, issued or

renewed in this state shall provide for credentialing and

recredentialing of physicians and other health care providers based

on criteria provided in the uniform credentialing application

required by Section 1-106.2 of Title 63 of the Oklahoma Statutes.

2. Health benefit plans shall make information on such criteria

available to physician and other health care provider applicants,

participating physicians, and other participating health care

providers and shall provide applicants with a checklist of materials

required in the application process.

3. Physicians or other health care providers under

consideration to provide health care services under a health benefit

plan in this state shall apply for credentialing or recredentialing

on the uniform credentialing application and shall provide the

documentation as outlined in the plan’s checklist of materials

required in the application process.

C. A health benefit plan shall determine whether a

credentialing or recredentialing application is complete. If an

application is determined to be incomplete, the plan shall notify

the applicant in writing within ten (10) calendar days of receipt of

the application. The written notice shall specify the portion of

the application that is causing a delay in processing and explain

any additional information or corrections needed.

D. 1. In reviewing the application, the health benefit plan

shall evaluate each application according to the plan’s checklist of

required materials that accompanies the application.

2. When an application is deemed complete, the plan shall

initiate requests for primary source verification and malpractice

history within seven (7) calendar days.

3. A malpractice carrier shall have twenty-one (21) calendar

days within which to respond after receipt of an inquiry from a
ach application according to the plan’s checklist of

required materials that accompanies the application.

2. When an application is deemed complete, the plan shall

initiate requests for primary source verification and malpractice

history within seven (7) calendar days.

3. A malpractice carrier shall have twenty-one (21) calendar

days within which to respond after receipt of an inquiry from a

health benefit plan. Any malpractice carrier that fails to respond

to an inquiry within the time frame may be assessed an

administrative penalty by the Insurance Commissioner.

E. 1. Upon receipt of primary source verification and

malpractice history by the plan, the plan shall determine if the

application is a clean application. If the application is deemed

clean, a plan shall have forty-five (45) calendar days within which

to credential or recredential a physician or other health care

provider. As used in this paragraph, “clean application” means an

application that has no defect, misstatement of facts,

improprieties, including a lack of any required substantiating

documentation, or particular circumstance requiring special

treatment that impedes prompt credentialing or recredentialing.

Oklahoma Statutes - Title 36. Insurance Page 953

2. If a plan is unable to credential or recredential a

physician or other health care provider due to an application not

being clean, the plan may extend the credentialing or

recredentialing process for sixty (60) calendar days. At the end of

sixty (60) calendar days, if the plan is awaiting documentation to

complete the application, the physician or other health care

provider shall be notified of the reason for the delay by certified

mail. The physician or other health care provider may extend the

sixty-day period upon written notice to the plan within ten (10)

calendar days; otherwise the application shall be deemed withdrawn.

In no event shall the entire credentialing or recredentialing

process exceed one hundred eighty (180) calendar days.

3. If an application for credentialing or recredentialing is

denied, the plan shall notify the applicant in writing the reason

for the denial and what corrective actions the applicant may

consider within ten (10) calendar days of the determination to deny

the application.

4. A health benefit plan shall be prohibited from solely basing

a denial of an application for credentialing or recredentialing on

the lack of board certification or board eligibility and from adding

new requirements solely for the purpose of delaying an application.

5. Any health benefit plan that violates the provisions of this

section may be assessed an administrative penalty by the

Commissioner.

F. Within thirty-one (31) days after a provider has been

credentialed by a health benefit plan following the completion of

the credentialing or recredentialing process pursuant to this

section, the health benefit plan shall consider the provider in-

network for purposes of reimbursement.