Okla. Stat. tit. 36, § 36-6559

review.

A. Insurance companies and not-for-profit hospital services and

medical indemnity plans licensed by the Commissioner that perform

in-house utilization review shall submit to the Commissioner the

following information regarding utilization review:

1. A utilization review plan that includes:

a. an adequate summary description of review standards,

protocol and procedures to be used in evaluating

proposed or delivered hospital and medical care,

b. assurances that the standards and criteria to be

applied in review determinations are established with

input from health care providers representing major

areas of specialty and certified by the boards of the

various American medical specialties, and

c. the provisions by which patients or health care

providers may seek reconsideration or appeal of

adverse decisions concerning requests for medical

evaluation, treatment or procedures;

2. The type and qualifications of the personnel either employed

or under contract to perform the utilization review;

3. The procedures and policies to ensure that a representative

is reasonably accessible to patients and health care providers five

(5) days a week during normal business hours, such procedures and

policies to include as a requirement a toll-free telephone number to

be available during said business hours; provided, in the case of

insurance companies, if the personnel performing utilization review

are out-of-state, the personnel shall be available or make staff

available by toll-free telephone for at least forty (40) hours per

week during normal business hours and shall have a telephone system

which is capable of accepting or recording incoming telephone calls

during other than normal hours, and shall respond to such calls

within two (2) working days, if sufficient information for response

is provided to whomever accepts the call or on a recorded message;

4. The policies and procedures to ensure that all applicable

state and federal laws to protect the confidentiality of individual

medical records are followed;

5. The policies and procedures to verify the identity and

authority of personnel performing utilization review by telephone;

6. A copy of the materials designed to inform applicable

patients and health care providers of the requirements of the

utilization review plan;

7. The procedures for receiving and handling complaints by

patients, hospitals and health care providers concerning utilization

review; and

8. Procedures to ensure that after a request for medical

evaluation, treatment, or procedures has been rejected in whole or

Oklahoma Statutes - Title 36. Insurance Page 1304

in part and in the event a copy of the report on said rejection is

requested, a copy of the report of the personnel performing

utilization review concerning the rejection shall be mailed by the

insurer, postage prepaid, to the ill or injured person, the treating

health care provider, hospital or to the person financially

responsible for the patient's bill within fifteen (15) days after

receipt of the request for the report.

B. Insurance companies that provide for in-house utilization

review shall pay an annual fee to the Insurance Commissioner of Five

Hundred Dollars ($500.00).