Okla. Stat. tit. 36, § 36-6475.13

A. To be approved under Section 6475.12 of this title to

conduct external reviews, an independent review organization shall

have and maintain written policies and procedures that govern all

aspects of both the standard external review process and the

expedited external review process set forth in this act that

include, at a minimum:

1. A quality assurance mechanism in place that:

a. ensures that external reviews are conducted within the

specified time frames and required notices are

provided in a timely manner,

b. ensures the selection of qualified and impartial

clinical reviewers to conduct external reviews on

behalf of the independent review organization and

suitable matching of reviewers to specific cases and

that the independent review organization employs or

contracts with an adequate number of clinical

reviewers to meet this objective,

c. ensures the confidentiality of medical and treatment

records and clinical review criteria, and

d. ensures that any person employed by or under contract

with the independent review organization adheres to

the requirements of the Uniform Health Carrier

External Review Act;

2. A toll-free telephone service to receive information on a

twenty-four-hour-a-day, seven-day-a-week basis related to external

reviews that is capable of accepting, recording or providing

appropriate instruction to incoming telephone callers during other

than normal business hours; and

3. Agree to maintain and provide to the Insurance Commissioner

the information set out in Section 6475.15 of this title.

Oklahoma Statutes - Title 36. Insurance Page 1267

B. All clinical reviewers assigned by an independent review

organization to conduct external reviews shall be physicians or

other appropriate health care providers who meet the following

minimum qualifications:

1. Be an expert in the treatment of the covered person's

medical condition that is the subject of the external review;

2. Be knowledgeable about the recommended health care service

or treatment through recent or current actual clinical experience

treating patients with the same or similar medical condition of the

covered person;

3. Hold a nonrestricted license in a state of the United States

and, for physicians, a current certification by a recognized

American medical specialty board in the area or areas appropriate to

the subject of the external review; and

4. Have no history of disciplinary actions or sanctions,

including loss of staff privileges or participation restrictions,

that have been taken or are pending by any hospital, governmental

agency or unit, or regulatory body that raise a substantial question

as to the clinical reviewer's physical, mental or professional

competence or moral character.

C. In addition to the requirements set forth in subsection A of

this section, an independent review organization may not own or

control, be a subsidiary of or in any way be owned or controlled by,

or exercise control with a health benefit plan, a national, state or

local trade association of health benefit plans, or a national,

state or local trade association of health care providers.

D. 1. In addition to the requirements set forth in subsections

A, B and C of this section, to be approved pursuant to Section

6475.12 of this title to conduct an external review of a specified

case, neither the independent review organization selected to

conduct the external review nor any clinical reviewer assigned by

the independent organization to conduct the external review may have

a material professional, familial or financial conflict of interest

with any of the following:

a. the health carrier that is the subject of the external

review,

b. the covered person whose treatment is the subject of

the external review or the covered person's authorized

representative,

c. any officer, director or management employee of the

health carrier that is the subject of the external

review,
professional, familial or financial conflict of interest

with any of the following:

a. the health carrier that is the subject of the external

review,

b. the covered person whose treatment is the subject of

the external review or the covered person's authorized

representative,

c. any officer, director or management employee of the

health carrier that is the subject of the external

review,

d. the health care provider, the health care provider's

medical group or independent practice association

recommending the health care service or treatment that

is the subject of the external review,

Oklahoma Statutes - Title 36. Insurance Page 1268

e. the facility at which the recommended health care

service or treatment would be provided, or

f. the developer or manufacturer of the principal drug,

device, procedure or other therapy being recommended

for the covered person whose treatment is the subject

of the external review.

2. In determining whether an independent review organization or

a clinical reviewer of the independent review organization has a

material professional, familial or financial conflict of interest

for purposes of paragraph 1 of this subsection, the Commissioner

shall take into consideration situations where the independent

review organization to be assigned to conduct an external review of

a specified case or a clinical reviewer to be assigned by the

independent review organization to conduct an external review of a

specified case may have an apparent professional, familial or

financial relationship or connection with a person described in

paragraph 1 of this subsection, but that the characteristics of that

relationship or connection are such that they are not a material

professional, familial or financial conflict of interest that

results in the disapproval of the independent review organization or

the clinical reviewer from conducting the external review.

E. In addition to the requirements set forth in subsections A,

B, C and D of this section, an independent review organization shall

possess any additional minimum qualifications that the Insurance

Commissioner may promulgate by rule.

F. 1. An independent review organization that is accredited by

a nationally recognized private accrediting entity that has

independent review accreditation standards that the Commissioner has

determined are equivalent to or exceed the minimum qualifications of

this section shall be presumed in compliance with this section to be

eligible for approval under Section 6475.12 of this title. If a

nationally recognized private accrediting entity has independent

review accreditation standards that are substantially similar to but

do not equal or exceed the minimum qualifications of this section,

the Commissioner may accept the accreditation as an equivalent

accreditation standard after reviewing for compliance any minimum

qualifications required by this section that are not required by the

national accreditation.

2. The Commissioner shall initially review and periodically

review the independent review organization accreditation standards

of a nationally recognized private accrediting entity to determine

whether the entity's standards are, and continue to be, equivalent

to or exceed the minimum qualifications established under this

section. The Commissioner may accept a review conducted by the NAIC

for the purpose of the determination under this paragraph.

3. Upon request, a nationally recognized private accrediting

entity shall make its current independent review organization

Oklahoma Statutes - Title 36. Insurance Page 1269

accreditation standards available to the Commissioner or the NAIC in

order for the Commissioner to determine if the entity's standards

are equivalent to or exceed the minimum qualifications established

under this section. The Commissioner may exclude any private

accrediting entity that is not reviewed by the NAIC.
ependent review organization

Oklahoma Statutes - Title 36. Insurance Page 1269

accreditation standards available to the Commissioner or the NAIC in

order for the Commissioner to determine if the entity's standards

are equivalent to or exceed the minimum qualifications established

under this section. The Commissioner may exclude any private

accrediting entity that is not reviewed by the NAIC.

G. An independent review organization shall be unbiased. An

independent review organization shall establish and maintain written

procedures to ensure that it is unbiased in addition to any other

procedures required under this section.