Okla. Stat. tit. 36, § 36-6475.3

For purposes of the Uniform Health Carrier External Review Act:

1. “Adverse determination” means a determination by a health

carrier or its designee utilization review organization that an

admission, availability of care, continued stay or other health care

service that is a covered benefit has been reviewed and, based upon

the information provided, does not meet the health carrier’s

requirements for medical necessity, appropriateness, health care

setting, level of care or effectiveness, and the requested service

or payment for the service is therefore denied, reduced or

terminated;

2. “Ambulatory review” means utilization review of health care

services performed or provided in an outpatient setting;

3. “Authorized representative” means:

a. a person to whom a covered person has given express

written consent to represent the covered person in an

external review,

b. a person authorized by law to provide substituted

consent for a covered person, or

c. a family member of the covered person or the covered

person’s treating health care professional only when

the covered person is unable to provide consent;

4. “Best evidence” means evidence based on:

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a. randomized clinical trials,

b. if randomized clinical trials are not available,

cohort studies or case-control studies,

c. if subparagraphs a and b of this paragraph are not

available, case-series, or

d. if subparagraphs a, b and c of this paragraph are not

available, expert opinion;

5. “Case-control study” means a retrospective evaluation of two

groups of patients with different outcomes to determine which

specific interventions the patients received;

6. “Case management” means a coordinated set of activities

conducted for individual patient management of serious, complicated,

protracted or other health conditions;

7. “Case-series” means an evaluation of a series of patients

with a particular outcome, without the use of a control group;

8. “Certification” means a determination by a health carrier or

its designee utilization review organization that an admission,

availability of care, continued stay or other health care service

has been reviewed and, based on the information provided, satisfies

the health carrier’s requirements for medical necessity,

appropriateness, health care setting, level of care and

effectiveness;

9. “Clinical review criteria” means the written screening

procedures, decision abstracts, clinical protocols and practice

guidelines used by a health carrier to determine the necessity and

appropriateness of health care services;

10. “Cohort study” means a prospective evaluation of two groups

of patients with only one group of patients receiving a specific

intervention or specific interventions;

11. “Commissioner” means the Insurance Commissioner;

12. “Concurrent review” means utilization review conducted

during a hospital stay or course of treatment of a patient;

13. “Covered benefits” or “benefits” means those health care

services to which a covered person is entitled under the terms of a

health benefit plan;

14. “Covered person” means a policyholder, subscriber, enrollee

or other individual participating in a health benefit plan;

15. “Discharge planning” means the formal process for

determining, prior to discharge from a facility, the coordination

and management of the care that a patient receives following

discharge from a facility;

16. “Disclose” means to release, transfer or otherwise divulge

protected health information to any person other than the individual

who is the subject of the protected health information;

17. “Emergency medical condition” means the sudden and, at the

time, unexpected onset of a health condition or illness that

requires immediate medical attention, where failure to provide

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medical attention would result in a serious impairment to bodily
any person other than the individual

who is the subject of the protected health information;

17. “Emergency medical condition” means the sudden and, at the

time, unexpected onset of a health condition or illness that

requires immediate medical attention, where failure to provide

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medical attention would result in a serious impairment to bodily

functions, serious dysfunction of a bodily organ or part, or would

place the person’s health in serious jeopardy;

18. “Emergency services” means health care items and services

furnished or required to evaluate and treat an emergency medical

condition;

19. “Evidence-based standard” means the conscientious, explicit

and judicious use of the current best evidence based on the overall

systematic review of the research in making decisions about the care

of individual patients;

20. “Expert opinion” means a belief or an interpretation by

specialists with experience in a specific area about the scientific

evidence pertaining to a particular service, intervention or

therapy;

21. “Facility” means an institution providing health care

services or a health care setting, including but not limited to

hospitals and other licensed inpatient centers, ambulatory surgical

or treatment centers, skilled nursing centers, residential treatment

centers, diagnostic, laboratory and imaging centers, and

rehabilitation and other therapeutic health settings;

22. “Final adverse determination” means an adverse

determination involving a covered benefit that has been upheld by a

health carrier, or its designee utilization review organization, at

the completion of the health carrier’s internal grievance process

procedures;

23. “Health benefit plan” means a policy, contract, certificate

or agreement offered or issued by a health carrier to provide,

deliver, arrange for, pay for or reimburse any of the costs of

health care services;

24. “Health care professional” means a physician or other

health care practitioner licensed, accredited or certified to

perform specified health care services consistent with state law;

25. “Health care provider” or “provider” means a health care

professional or a facility;

26. “Health care services” means services for the diagnosis,

prevention, treatment, cure or relief of a health condition,

illness, injury or disease;

27. “Health carrier” means an entity subject to the insurance

laws and regulations of this state, or subject to the jurisdiction

of the Commissioner, that contracts or offers to contract to

provide, deliver, arrange for, pay for or reimburse any of the costs

of health care services, including but not limited to a sickness and

accident insurance company, a health maintenance organization, a

nonprofit hospital and health service corporation, or any other

entity providing a plan of health insurance, health benefits or

health care services;

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28. “Health information” means information or data, whether

oral or recorded in any form or medium, and personal facts or

information about events or relationships that relate to:

a. the past, present or future physical, mental, or

behavioral health or condition of an individual or a

member of the individual’s family,

b. the provision of health care services to an

individual, or

c. payment for the provision of health care services to

an individual;

29. “Independent review organization” means an entity that

conducts independent external reviews of adverse determinations and

final adverse determinations;

30. “Medical or scientific evidence” means evidence found in

the following sources:

a. peer-reviewed scientific studies published in or

accepted for publication by medical journals that meet

nationally recognized requirements for scientific

manuscripts and that submit most of the published

articles for review by experts who are not part of the

editorial staff,
final adverse determinations;

30. “Medical or scientific evidence” means evidence found in

the following sources:

a. peer-reviewed scientific studies published in or

accepted for publication by medical journals that meet

nationally recognized requirements for scientific

manuscripts and that submit most of the published

articles for review by experts who are not part of the

editorial staff,

b. peer-reviewed medical literature, including literature

relating to therapies reviewed and approved by a

qualified institutional review board, biomedical

compendia and other medical literature that meet the

criteria of the National Institutes of Health’s

Library of Medicine for indexing in Index Medicus

(Medline) and Elsevier Science Ltd. for indexing in

Excerpta Medicus (EMBASE),

c. medical journals recognized by the Secretary of Health

and Human Services under Section 1861(t)(2) of the

federal Social Security Act,

d. the following standard reference compendia:

(1) the American Hospital Formulary Service–Drug

Information,

(2) Drug Facts and Comparisons,

(3) the American Dental Association Accepted Dental

Therapeutics, and

(4) the United States Pharmacopoeia–Drug Information,

e. findings, studies or research conducted by or under

the auspices of federal government agencies and

nationally recognized federal research institutes,

including but not limited to:

(1) the federal Agency for Healthcare Research and

Quality,

(2) the National Institutes of Health,

(3) the National Cancer Institute,

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(4) the National Academy of Sciences,

(5) the Centers for Medicare and Medicaid Services,

(6) the federal Food and Drug Administration, and

(7) any national board recognized by the National

Institutes of Health for the purpose of

evaluating the medical value of health care

services, or

f. any other medical or scientific evidence that is

comparable to the sources listed in subparagraphs a

through e of this paragraph;

31. “NAIC” means the National Association of Insurance

Commissioners;

32. “Person” means an individual, a corporation, a partnership,

an association, a joint venture, a joint stock company, a trust, an

unincorporated organization, any similar entity or any combination

of the foregoing;

33. “Prospective review” means utilization review conducted

prior to an admission or a course of treatment;

34. “Protected health information” means health information:

a. that identifies an individual who is the subject of

the information, or

b. with respect to which there is a reasonable basis to

believe that the information could be used to identify

an individual;

35. “Randomized clinical trial” means a controlled, prospective

study of patients that have been randomized into an experimental

group and a control group at the beginning of the study with only

the experimental group of patients receiving a specific

intervention, which includes study of the groups for variables and

anticipated outcomes over time;

36. “Retrospective review” means a review of medical necessity

conducted after services have been provided to a patient, but does

not include the review of a claim that is limited to an evaluation

of reimbursement levels, veracity of documentation, accuracy of

coding or adjudication for payment;

37. “Second opinion” means an opportunity or requirement to

obtain a clinical evaluation by a provider other than the one

originally making a recommendation for a proposed health care

service to assess the clinical necessity and appropriateness of the

initial proposed health care service;

38. “Utilization review” means a set of formal techniques

designed to monitor the use of, or evaluate the clinical necessity,

appropriateness, efficacy, or efficiency of, health care services,

procedures, or settings. Techniques may include but are not limited

to ambulatory review, prospective review, second opinion,
necessity and appropriateness of the

initial proposed health care service;

38. “Utilization review” means a set of formal techniques

designed to monitor the use of, or evaluate the clinical necessity,

appropriateness, efficacy, or efficiency of, health care services,

procedures, or settings. Techniques may include but are not limited

to ambulatory review, prospective review, second opinion,

certification, concurrent review, case management, discharge

planning, or retrospective review; and

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39. “Utilization review organization” means an entity that

conducts utilization review, other than a health carrier performing

a review for its own health benefit plans.