Okla. Stat. tit. 36, § 36-6475.10

A. 1. Within four (4) months after the date of receipt of a

notice of an adverse determination or final adverse determination

pursuant to Section 6475.5 of this title that involves a denial of

coverage based on a determination that the health care service or

treatment recommended or requested is experimental or

investigational, a covered person or the covered person's authorized

representative may file a request for external review with the

Insurance Commissioner.

2. a. A covered person or the covered person's authorized

representative may make an oral request for an

expedited external review of the adverse determination

or final adverse determination pursuant to paragraph 1

of this subsection if the covered person's treating

physician certifies, in writing, that the recommended

or requested health care service or treatment that is

the subject of the request would be significantly less

effective if not promptly initiated.

b. Upon receipt of a request for an expedited external

review, the Commissioner immediately shall notify the

health carrier.

c. (1) Upon notice of the request for expedited external

review, the health carrier immediately shall

determine whether the request meets the

reviewability requirements of subsection B of

this section. The health carrier shall

immediately notify the Commissioner and the

covered person and, if applicable, the covered

person's authorized representative of its

eligibility determination.

(2) The Commissioner may specify the form for the

health carrier's notice of initial determination

under division (1) of this subparagraph and any

supporting information to be included in the

notice.

(3) The notice of initial determination under

division (1) of this subparagraph shall include a

statement informing the covered person and, if

applicable, the covered person's authorized

representative that a health carrier's initial

determination that the external review request is

ineligible for review may be appealed to the

Commissioner.

d. (1) The Commissioner may determine that a request is

eligible for external review under paragraph 2 of

subsection B of this section notwithstanding a

Oklahoma Statutes - Title 36. Insurance Page 1255

health carrier's initial determination the

request is ineligible and require that it be

referred for external review.

(2) In making a determination under division (1) of

this subparagraph, the Commissioner's decision

shall be made in accordance with the terms of the

covered person's health benefit plan and shall be

subject to all applicable provisions of the

Uniform Health Carrier External Review Act.

e. Upon receipt of the notice that the expedited external

review request meets the reviewability requirements of

paragraph 2 of subsection B of this section, the

Commissioner immediately shall assign an independent

review organization to review the expedited request

from the list of approved independent review

organizations compiled and maintained by the

Commissioner pursuant to Section 6475.12 of this title

and notify the health carrier of the name of the

assigned independent review organization.

f. At the time the health carrier receives the notice of

the assigned independent review organization pursuant

to subparagraph e of this paragraph, the health

carrier or its designee utilization review

organization shall provide or transmit all necessary

documents and information considered in making the

adverse determination or final adverse determination

to the assigned independent review organization

electronically or by telephone or facsimile or any

other available expeditious method.

B. 1. Except for a request for an expedited external review

made pursuant to paragraph 2 of subsection A of this section, within

one (1) business day after the date of receipt of the request, the

Commissioner receives a request for an external review, the

Commissioner shall notify the health carrier.
tion

electronically or by telephone or facsimile or any

other available expeditious method.

B. 1. Except for a request for an expedited external review

made pursuant to paragraph 2 of subsection A of this section, within

one (1) business day after the date of receipt of the request, the

Commissioner receives a request for an external review, the

Commissioner shall notify the health carrier.

2. Within five (5) business days following the date of receipt

of the notice sent pursuant to paragraph 1 of this subsection, the

health carrier shall conduct and complete a preliminary review of

the request to determine whether:

a. the individual is or was a covered person in the

health benefit plan at the time the health care

service or treatment was recommended or requested or,

in the case of a retrospective review, was a covered

person in the health benefit plan at the time the

health care service or treatment was provided,

b. the recommended or requested health care service or

treatment that is the subject of the adverse

determination or final adverse determination:

Oklahoma Statutes - Title 36. Insurance Page 1256

(1) is a covered benefit under the covered person's

health benefit plan except for the health

carrier's determination that the service or

treatment is experimental or investigational for

a particular medical condition, and

(2) is not explicitly listed as an excluded benefit

under the covered person's health benefit plan

with the health carrier,

c. the covered person's treating physician has certified

that one of the following situations is applicable:

(1) standard health care services or treatments have

not been effective in improving the condition of

the covered person,

(2) standard health care services or treatments are

not medically appropriate for the covered person,

or

(3) there is no available standard health care

service or treatment covered by the health

carrier that is more beneficial than the

recommended or requested health care service or

treatment described in subparagraph d of this

paragraph,

d. the covered person's treating physician:

(1) has recommended a health care service or

treatment that the physician certifies, in

writing, is likely to be more beneficial to the

covered person, in the physician's opinion, than

any available standard health care services or

treatments, or

(2) who is a licensed, board-certified or board-

eligible physician qualified to practice in the

area of medicine appropriate to treat the covered

person's condition, has certified in writing that

scientifically valid studies using accepted

protocols demonstrate that the health care

service or treatment requested by the covered

person that is the subject of the adverse

determination or final adverse determination is

likely to be more beneficial to the covered

person than any available standard health care

services or treatments,

e. the covered person has exhausted the health carrier's

internal grievance process unless the covered person

is not required to exhaust the health carrier's

internal grievance process pursuant to Section 6475.7

of this title, and

Oklahoma Statutes - Title 36. Insurance Page 1257

f. the covered person has provided all the information

and forms required by the Commissioner that are

necessary to process an external review including the

release form provided under subsection B of Section

6475.5 of this title.

C. 1. Within one (1) business day after completion of the

preliminary review, the health carrier shall notify the Commissioner

and the covered person and, if applicable, the covered person's

authorized representative in writing whether:

a. the request is complete, and

b. the request is eligible for external review.

2. If the request:

a. is not complete, the health carrier shall inform in

writing the Commissioner and the covered person and,

if applicable, the covered person's authorized
hall notify the Commissioner

and the covered person and, if applicable, the covered person's

authorized representative in writing whether:

a. the request is complete, and

b. the request is eligible for external review.

2. If the request:

a. is not complete, the health carrier shall inform in

writing the Commissioner and the covered person and,

if applicable, the covered person's authorized

representative and include in the notice what

information or materials are needed to make the

request complete, or

b. is not eligible for external review, the health

carrier shall inform the covered person, the covered

person's authorized representative, if applicable, and

the Commissioner in writing and include in the notice

the reasons for its ineligibility.

3. a. The Commissioner may specify the form for the health

carrier's notice of initial determination under

paragraph 2 of this subsection and any supporting

information to be included in the notice.

b. The notice of initial determination provided under

paragraph 2 of this subsection shall include a

statement informing the covered person and, if

applicable, the covered person's authorized

representative that a health carrier's initial

determination that the external review request is

ineligible for review may be appealed to the

Commissioner.

4. a. The Commissioner may determine that a request is

eligible for external review under paragraph 2 of

subsection B of this section notwithstanding a health

carrier's initial determination that the request is

ineligible and require that it be referred for

external review.

b. In making a determination under subparagraph a of this

paragraph, the Commissioner's decision shall be made

in accordance with the terms of the covered person's

health benefit plan and shall be subject to all

applicable provisions of the Uniform Health Carrier

External Review Act.

Oklahoma Statutes - Title 36. Insurance Page 1258

5. Whenever a request for external review is determined

eligible for external review, the health carrier shall notify the

Commissioner and the covered person and, if applicable, the covered

person's authorized representative.

D. 1. Within one (1) business day after the receipt of the

notice from the health carrier that the external review request is

eligible for external review pursuant to subparagraph d of paragraph

2 of subsection A of this section or paragraph 5 of subsection C of

this section, the Commissioner shall:

a. assign an independent review organization to conduct

the external review from the list of approved

independent review organizations compiled and

maintained by the Commissioner pursuant to Section

6475.12 of this title and notify the health carrier of

the name of the assigned independent review

organization, and

b. notify in writing the covered person and, if

applicable, the covered person's authorized

representative of the request's eligibility and

acceptance for external review.

2. The Commissioner shall include in the notice provided to the

covered person and, if applicable, the covered person's authorized

representative a statement that the covered person or the covered

person's authorized representative may submit in writing to the

assigned independent review organization within five (5) business

days following the date of receipt of the notice provided pursuant

to paragraph 1 of this subsection, additional information that the

independent review organization shall consider when conducting the

external review. The independent review organization is not

required to, but may, accept and consider additional information

submitted after five (5) business days.

3. Within one (1) business day after the receipt of the notice

of assignment to conduct the external review pursuant to paragraph 1

of this subsection, the assigned independent review organization

shall:

a. select one or more clinical reviewers, as it
dependent review organization is not

required to, but may, accept and consider additional information

submitted after five (5) business days.

3. Within one (1) business day after the receipt of the notice

of assignment to conduct the external review pursuant to paragraph 1

of this subsection, the assigned independent review organization

shall:

a. select one or more clinical reviewers, as it

determines is appropriate, pursuant to paragraph 4 of

this subsection to conduct the external review, and

b. based on the opinion of the clinical reviewer, or

opinions if more than one clinical reviewer has been

selected to conduct the external review, make a

decision to uphold or reverse the adverse

determination or final adverse determination.

4. a. In selecting clinical reviewers pursuant to

subparagraph a of paragraph 3 of this subsection, the

assigned independent review organization shall select

physicians or other health care professionals who meet

Oklahoma Statutes - Title 36. Insurance Page 1259

the minimum qualifications described in Section

6475.13 of this title and, through clinical experience

in the past three (3) years, are experts in the

treatment of the covered person's condition and

knowledgeable about the recommended or requested

health care service or treatment.

b. Neither the covered person, the covered person's

authorized representative, if applicable, nor the

health carrier, shall choose or control the choice of

the physicians or other health care professionals to

be selected to conduct the external review.

5. In accordance with subsection H of this section, each

clinical reviewer shall provide a written opinion to the assigned

independent review organization on whether the recommended or

requested health care service or treatment should be covered.

6. In reaching an opinion, clinical reviewers are not bound by

any decisions or conclusions reached during the health carrier's

utilization review process as set forth in Sections 6551 through

6565 of this title or the health carrier's internal grievance

process.

E. 1. Within five (5) business days after the date of receipt

of the notice provided pursuant to paragraph 1 of subsection D of

this section, the health carrier or its designee utilization review

organization shall provide to the assigned independent review

organization the documents and any information considered in making

the adverse determination or the final adverse determination.

2. Except as provided in paragraph 3 of this subsection,

failure by the health carrier or its designee utilization review

organization to provide the documents and information within the

time specified in paragraph 1 of this subsection shall not delay the

conduct of the external review.

3. a. If the health carrier or its designee utilization

review organization has failed to provide the

documents and information within the time specified in

paragraph 1 of this subsection, the assigned

independent review organization may terminate the

external review and make a decision to reverse the

adverse determination or final adverse determination.

b. Immediately upon making the decision under

subparagraph a of this paragraph, the independent

review organization shall notify the covered person,

the covered person's authorized representative, if

applicable, the health carrier, and the Commissioner.

F. 1. Each clinical reviewer selected pursuant to subsection D

of this section shall review all of the information and documents

received pursuant to subsection E of this section and any other

information submitted in writing by the covered person or the

Oklahoma Statutes - Title 36. Insurance Page 1260

covered person's authorized representative pursuant to paragraph 2

of subsection D of this section.

2. Upon receipt of any information submitted by the covered

person or the covered person's authorized representative pursuant to
ursuant to subsection E of this section and any other

information submitted in writing by the covered person or the

Oklahoma Statutes - Title 36. Insurance Page 1260

covered person's authorized representative pursuant to paragraph 2

of subsection D of this section.

2. Upon receipt of any information submitted by the covered

person or the covered person's authorized representative pursuant to

paragraph 2 of subsection D of this section, within one (1) business

day after the receipt of the information, the assigned independent

review organization shall forward the information to the health

carrier.

G. 1. Upon receipt of the information required to be forwarded

pursuant to paragraph 2 of subsection F of this section, the health

carrier may reconsider its adverse determination or final adverse

determination that is the subject of the external review.

2. Reconsideration by the health carrier of its adverse

determination or final adverse determination pursuant to paragraph 1

of this subsection shall not delay or terminate the external review.

3. The external review may be terminated only if the health

carrier decides, upon completion of its reconsideration, to reverse

its adverse determination or final adverse determination and provide

coverage or payment for the recommended or requested health care

service or treatment that is the subject of the adverse

determination or final adverse determination.

4. a. Immediately upon making the decision to reverse its

adverse determination or final adverse determination,

as provided in paragraph 3 of this subsection, the

health carrier shall notify the covered person, the

covered person's authorized representative if

applicable, the assigned independent review

organization, and the Commissioner in writing of its

decision.

b. The assigned independent review organization shall

terminate the external review upon receipt of the

notice from the health carrier sent pursuant to

subparagraph a of this paragraph.

H. 1. Except as provided in paragraph 3 of this subsection,

within twenty (20) days after being selected in accordance with

subsection D of this section to conduct the external review, each

clinical reviewer shall provide an opinion to the assigned

independent review organization pursuant to subsection I of this

section on whether the recommended or requested health care service

or treatment should be covered.

2. Except for an opinion provided pursuant to paragraph 3 of

this subsection, each clinical reviewer's opinion shall be in

writing and include the following information:

a. a description of the covered person's medical

condition,

b. a description of the indicators relevant to

determining whether there is sufficient evidence to

Oklahoma Statutes - Title 36. Insurance Page 1261

demonstrate that the recommended or requested health

care service or treatment is more likely than not to

be beneficial to the covered person than any available

standard health care services or treatments and the

adverse risks of the recommended or requested health

care service or treatment would not be substantially

increased over those of available standard health care

services or treatments,

c. a description and analysis of any medical or

scientific evidence, as that term is defined in

Section 6475.3 of this title, considered in reaching

the opinion,

d. a description and analysis of any evidence-based

standard, as that term is defined in Section 6475.3 of

this title, and

e. information on whether the reviewer's rationale for

the opinion is based on subparagraph a or b of

paragraph 5 of subsection I of this section.

3. a. For an expedited external review, each clinical

reviewer shall provide an opinion orally or in writing

to the assigned independent review organization as

expeditiously as the covered person's medical

condition or circumstances require, but in no event

more than five (5) calendar days after being selected
n is based on subparagraph a or b of

paragraph 5 of subsection I of this section.

3. a. For an expedited external review, each clinical

reviewer shall provide an opinion orally or in writing

to the assigned independent review organization as

expeditiously as the covered person's medical

condition or circumstances require, but in no event

more than five (5) calendar days after being selected

in accordance with subsection D of this section.

b. If the opinion provided pursuant to subparagraph a of

this paragraph was not in writing, within forty-eight

(48) hours following the date the opinion was provided

the clinical reviewer shall provide written

confirmation of the opinion to the assigned

independent review organization and include the

information required under paragraph 2 of this

subsection.

I. In addition to the documents and information provided

pursuant to paragraph 2 of subsection A of this section or

subsection E of this section, each clinical reviewer selected

pursuant to subsection D of this section, to the extent the

information or documents are available and the reviewer considers

appropriate, shall consider the following in reaching an opinion

pursuant to subsection H of this section:

1. The covered person's pertinent medical records;

2. The attending physician or health care professional's

recommendation;

3. Consulting reports from appropriate health care

professionals and other documents submitted by the health carrier,

covered person, the covered person's authorized representative, or

the covered person's treating physician or health care professional;

Oklahoma Statutes - Title 36. Insurance Page 1262

4. The terms of coverage under the covered person's health

benefit plan with the health carrier to ensure that, but for the

health carrier's determination that the recommended or requested

health care service or treatment that is the subject of the opinion

is experimental or investigational, the reviewer's opinion is not

contrary to the terms of coverage under the covered person's health

benefit plan with the health carrier; and

5. Whether:

a. the recommended or requested health care service or

treatment has been approved by the federal Food and

Drug Administration, if applicable, for the condition,

or

b. medical or scientific evidence or evidence-based

standards demonstrate that the expected benefits of

the recommended or requested health care service or

treatment is more likely than not to be beneficial to

the covered person than any available standard health

care service or treatment and the adverse risks of the

recommended or requested health care service or

treatment would not be substantially increased over

those of available standard health care services or

treatments.

J. 1. a. Except as provided in subparagraph b of this

paragraph, within twenty (20) days after the date it

receives the opinion of each clinical reviewer

pursuant to subsection I of this section, the assigned

independent review organization, in accordance with

paragraph 2 of this subsection, shall make a decision

and provide written notice of the decision to:

(1) the covered person,

(2) if applicable, the covered person's authorized

representative,

(3) the health carrier, and

(4) the Commissioner.

b. (1) For an expedited external review, within forty-

eight (48) hours after the date it receives the

opinion of each clinical reviewer pursuant to

subsection I of this section, the assigned

independent review organization, in accordance

with paragraph 2 of this subsection, shall make a

decision and provide notice of the decision

orally or in writing to the persons listed in

subparagraph a of this paragraph.
ted external review, within forty-

eight (48) hours after the date it receives the

opinion of each clinical reviewer pursuant to

subsection I of this section, the assigned

independent review organization, in accordance

with paragraph 2 of this subsection, shall make a

decision and provide notice of the decision

orally or in writing to the persons listed in

subparagraph a of this paragraph.

(2) If the notice provided under division (1) of this

subparagraph was not in writing, within forty-

eight (48) hours after the date of providing that

notice, the assigned independent review

Oklahoma Statutes - Title 36. Insurance Page 1263

organization shall provide written confirmation

of the decision to the persons listed in

subparagraph a of this paragraph and include the

information set forth in paragraph 3 of this

subsection.

2. a. If a majority of the clinical reviewers recommend that

the recommended or requested health care service or

treatment should be covered, the independent review

organization shall make a decision to reverse the

health carrier's adverse determination or final

adverse determination.

b. If a majority of the clinical reviewers recommend that

the recommended or requested health care service or

treatment should not be covered, the independent

review organization shall make a decision to uphold

the health carrier's adverse determination or final

adverse determination.

c. (1) If the clinical reviewers are evenly split as to

whether the recommended or requested health care

service or treatment should be covered, the

independent review organization shall obtain the

opinion of an additional clinical reviewer in

order for the independent review organization to

make a decision based on the opinions of a

majority of the clinical reviewers pursuant to

subparagraph a or b of this paragraph.

(2) The additional clinical reviewer selected under

division (1) of this subparagraph shall use the

same information to reach an opinion as the

clinical reviewers who have already submitted

their opinions pursuant to subsection I of this

section.

(3) The selection of the additional clinical reviewer

under this subparagraph shall not extend the time

within which the assigned independent review

organization is required to make a decision based

on the opinions of the clinical reviewers

selected pursuant to paragraph 1 of subsection D

of this section.

3. The independent review organization shall include in the

notice provided pursuant to paragraph 1 of this subsection:

a. a general description of the reason for the request

for external review,

b. the written opinion of each clinical reviewer

including the recommendation of each clinical reviewer

as to whether the recommended or requested health care

Oklahoma Statutes - Title 36. Insurance Page 1264

service or treatment should be covered and the

rationale for the reviewer's recommendation,

c. the date the independent review organization was

assigned by the Commissioner to conduct the external

review,

d. the date the external review was conducted,

e. the date of its decision,

f. the principal reason or reasons for its decision, and

g. the rationale for its decision.

4. Upon receipt of a notice of a decision pursuant to paragraph

1 of this subsection reversing the adverse determination or final

adverse determination, the health carrier immediately shall approve

coverage of the recommended or requested health care service or

treatment that was the subject of the adverse determination or final

adverse determination.

K. The assignment by the Commissioner of an approved

independent review organization to conduct an external review in

accordance with this section shall be done on a random basis among

those approved independent review organizations qualified to conduct

the particular external review based on the nature of the health

care service that is the subject of the adverse determination or
rmination.

K. The assignment by the Commissioner of an approved

independent review organization to conduct an external review in

accordance with this section shall be done on a random basis among

those approved independent review organizations qualified to conduct

the particular external review based on the nature of the health

care service that is the subject of the adverse determination or

final adverse determination and other circumstances including

conflict of interest concerns pursuant to subsection D of Section

6475.13 of this title.