Okla. Stat. tit. 36, § 36-6475.8

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, a covered person or the

covered person's authorized representative may file a request for an

external review with the Insurance Commissioner.

2. Within one (1) business day after the date of receipt of a

request for external review pursuant to paragraph 1 of this

subsection, the Commissioner shall send a copy of the request to the

health carrier.

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

of the copy of the external review request from the Commissioner

under paragraph 2 of subsection A of this section, the health

carrier shall complete a preliminary review of the request to

determine whether:

1. The individual is or was a covered person in the health

benefit plan at the time the health care service was requested or,

in the case of a retrospective review, was a covered person in the

Oklahoma Statutes - Title 36. Insurance Page 1246

health benefit plan at the time the health care service was

provided;

2. The health care service that is the subject of the adverse

determination or the final adverse determination is a covered

service under the covered person's health benefit plan, but for a

determination by the health carrier that the health care service is

not covered because it does not meet the health carrier's

requirements for medical necessity, appropriateness, health care

setting, level of care or effectiveness;

3. 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

4. The covered person has provided all the information and

forms required 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 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 the

covered person and, if applicable, the covered

person's authorized representative and the

Commissioner in writing 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, if

applicable, the covered person's authorized

representative 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 this

subsection and any supporting information to be

included in the notice.

b. The notice of initial determination 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.

Oklahoma Statutes - Title 36. Insurance Page 1247

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

eligible for external review under 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.
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.

D. 1. Whenever the Commissioner receives a notice that a

request is eligible for external review following the preliminary

review conducted pursuant to subsection C of this section, within

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

Commissioner shall:

a. assign an independent review organization from the

list of approved independent review organizations

compiled and maintained by the Commissioner pursuant

to Section 6475.12 of this title to conduct the

external review 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. In reaching a decision, the assigned independent review

organization shall not be bound by any decisions or conclusions

reached during the health carrier's utilization review process as

set forth in Sections 6551 through 6555 of this title or the health

carrier's internal grievance process.

3. 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.

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

Oklahoma Statutes - Title 36. Insurance Page 1248

organization the documents and any information considered in making

the adverse determination or final adverse determination.

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

failure by the health carrier or its 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 utilization review

organization fails 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. Within one (1) business day after making the decision

under subparagraph a of this paragraph, the

independent review organization shall notify the

covered person, if applicable, the covered person's

authorized representative, the health carrier, and the

Commissioner.

F. 1. The assigned independent review organization shall

review all of the information and documents received pursuant to

subsection E of this section and any other information submitted in

writing to the independent review organization by the covered person

or the covered person's authorized representative pursuant to

paragraph 3 of subsection D of this section.

2. Upon receipt of any information submitted by the covered
review organization shall

review all of the information and documents received pursuant to

subsection E of this section and any other information submitted in

writing to the independent review organization by the covered person

or the covered person's authorized representative pursuant to

paragraph 3 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 3 of subsection D of this section, the assigned

independent review organization shall within one (1) business day

forward the information to the health carrier.

G. 1. Upon receipt of the information, if any, 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 only be terminated 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 health care service that is the subject

of the adverse determination or final adverse determination.

4. a. Within one (1) business day after 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

Oklahoma Statutes - Title 36. Insurance Page 1249

covered person, if applicable, the covered person's

authorized representative, 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. In addition to the documents and information provided

pursuant to subsection E of this section, the assigned independent

review organization, to the extent the information or documents are

available and the independent review organization considers them

appropriate, shall consider the following in reaching a decision:

1. The covered person's medical records;

2. The attending 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 provider;

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

benefit plan with the health carrier to ensure that the independent

review organization's decision is not contrary to the terms of

coverage under the covered person's health benefit plan with the

health carrier;

5. The most appropriate practice guidelines, which shall

include applicable evidence-based standards and may include any

other practice guidelines developed by the federal government,

national or professional medical societies, boards and associations;

6. Any applicable clinical review criteria developed and used

by the health carrier or its designee utilization review

organization; and

7. The opinion of the independent review organization's

clinical reviewer or reviewers after considering paragraphs 1

through 6 of this subsection to the extent the information or

documents are available and the clinical reviewer or reviewers

consider appropriate.

I. 1. Within forty-five (45) days after the date of receipt of

the request for an external review, the assigned independent review

organization shall provide written notice of its decision to uphold

or reverse the adverse determination or the final adverse

determination to:

a. the covered person,
mation or

documents are available and the clinical reviewer or reviewers

consider appropriate.

I. 1. Within forty-five (45) days after the date of receipt of

the request for an external review, the assigned independent review

organization shall provide written notice of its decision to uphold

or reverse the adverse determination or the final adverse

determination to:

a. the covered person,

b. if applicable, the covered person's authorized

representative,

c. the health carrier, and

d. the Commissioner.

Oklahoma Statutes - Title 36. Insurance Page 1250

2. The independent review organization shall include in the

notice sent pursuant to paragraph 1 of this subsection:

a. a general description of the reason for the request

for external review,

b. the date the independent review organization received

the assignment from the Commissioner to conduct the

external review,

c. the date the external review was conducted,

d. the date of its decision,

e. the principal reason or reasons for its decision

including what applicable, if any, evidence-based

standards were a basis for its decision,

f. the rationale for its decision, and

g. references to the evidence or documentation including

the evidence-based standards, considered in reaching

its decision.

3. 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

the coverage that was the subject of the adverse determination or

final adverse determination.

J. 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.