Okla. Stat. tit. 36, § 36-6475.9

A. Except as provided in subsection F of this section, a

covered person or the covered person's authorized representative may

make a request for an expedited external review with the Insurance

Commissioner at the time the covered person receives:

1. An adverse determination if:

a. the adverse determination involves a medical condition

of the covered person for which the time frame for

completion of an expedited internal review of a

grievance involving an adverse determination would

seriously jeopardize the life or health of the covered

person or would jeopardize the covered person's

ability to regain maximum function, and

Oklahoma Statutes - Title 36. Insurance Page 1251

b. the covered person or the covered person's authorized

representative has filed a request for an expedited

review of a grievance involving an adverse

determination; or

2. A final adverse determination:

a. if the covered person has a medical condition where

the time frame for completion of a standard external

review pursuant to Section 6475.8 of this title would

seriously jeopardize the life or health of the covered

person or would jeopardize the covered person's

ability to regain maximum function, or

b. if the final adverse determination concerns an

admission, availability of care, continued stay or

health care service for which the covered person

received emergency services, but has not been

discharged from a facility.

B. 1. Upon receipt of a request for an expedited external

review, the Commissioner immediately shall send a copy of the

request to the health carrier.

2. Immediately upon receipt of the request pursuant to

paragraph 1 of this subsection, the health carrier shall determine

whether the request meets the reviewability requirements set forth

in subsection B of Section 6475.8 of this title. 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.

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 an 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 subsection B of

Section 6475.8 of this title 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

Oklahoma Statutes - Title 36. Insurance Page 1252

applicable provisions of the Uniform Health Carrier

External Review Act.

5. Upon receipt of the notice that the request meets the

reviewability requirements, the Commissioner immediately shall

assign an independent review organization to conduct the expedited

external review from the list of approved independent review

organizations compiled and maintained by the Commissioner pursuant

to Section 6475.12 of this title. The Commissioner shall

immediately notify the health carrier of the name of the assigned

independent review organization.

6. In reaching a decision in accordance with subsection E of

this section, 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 6565 of this title or the health carrier's internal

grievance process.
e of the assigned

independent review organization.

6. In reaching a decision in accordance with subsection E of

this section, 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 6565 of this title or the health carrier's internal

grievance process.

C. Upon receipt of the notice from the Commissioner of the name

of the independent review organization assigned to conduct the

expedited external review pursuant to paragraph 5 of subsection B of

this section, 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.

D. In addition to the documents and information provided or

transmitted pursuant to subsection C 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 pertinent 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 evidence-based standards, and may include any other practice

guidelines developed by the federal government, national or

professional medical societies, boards and associations;

Oklahoma Statutes - Title 36. Insurance Page 1253

6. Any applicable clinical review criteria developed and used

by the health carrier or its designee utilization review

organization in making adverse determinations; 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 and

documents are available and the clinical reviewer or reviewers

consider appropriate.

E. 1. As expeditiously as the covered person's medical

condition or circumstances require, but in no event more than

seventy-two (72) hours after the date of receipt of the request for

an expedited external review that meets the reviewability

requirements set forth in subsection B of Section 6475.8 of this

title, the assigned independent review organization shall:

a. make a decision to uphold or reverse the adverse

determination or final adverse determination, and

b. notify the covered person, if applicable, the covered

person's authorized representative, the health

carrier, and the Commissioner of the decision.

2. If the notice provided pursuant to paragraph 1 of this

subsection was not in writing, within forty-eight (48) hours after

the date of providing that notice, the assigned independent review

organization shall:

a. provide written confirmation of the decision to the

covered person, if applicable, the covered person's

authorized representative, the health carrier, and the

Commissioner, and

b. include the information set forth in paragraph 2 of

subsection I of Section 6475.8 of this title.

3. Upon receipt of the notice of a decision pursuant to

paragraph 1 of this subsection reversing the adverse determination

or final adverse determination, the health carrier immediately shall
cable, the covered person's

authorized representative, the health carrier, and the

Commissioner, and

b. include the information set forth in paragraph 2 of

subsection I of Section 6475.8 of this title.

3. Upon receipt of the 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.

F. An expedited external review may not be provided for

retrospective adverse or final adverse determinations.

G. 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.