Okla. Stat. tit. 36, § 36-6570.1

As used in this act:

1. "Adverse determination" means a determination by a health

carrier or its designee utilization review entity 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 as defined by Section 6475.3 of Title 36 of the Oklahoma

Statutes;

2. "Chronic condition" means a condition that lasts one (1)

year or more and requires ongoing medical attention or limits

activities of daily living or both;

Oklahoma Statutes - Title 36. Insurance Page 1307

3. "Clinical criteria" means the written policies, written

screening procedures, determination rules, determination abstracts,

clinical protocols, practice guidelines, medical protocols, and any

other criteria or rationale used by the utilization review entity to

determine the necessity and appropriateness of health care services;

4. "Emergency health care services", with respect to an

emergency medical condition as defined in 42 U.S.C.A., Section

300gg-111, means:

a. a medical screening examination, as required under

Section 1867 of the Social Security Act, 42 U.S.C.,

Section 1395dd, or as would be required under such

section if such section applied to an independent,

freestanding emergency department, that is within the

capability of the emergency department of a hospital

or of an independent, freestanding emergency

department, as applicable, including ancillary

services routinely available to the emergency

department to evaluate such emergency medical

condition, and

b. within the capabilities of the staff and facilities

available at the hospital or the independent,

freestanding emergency department, as applicable, such

further medical examination and treatment as are

required under Section 1395dd of the Social Security

Act, or as would be required under such section if

such section applied to an independent, freestanding

emergency department, to stabilize the patient,

regardless of the department of the hospital in which

such further examination or treatment is furnished, as

defined by 42 U.S.C.A., Section 300gg-111;

5. "Emergency Medical Treatment and Active Labor Act" or

"EMTALA" means Section 1867 of the Social Security Act and

associated regulations;

6. "Enrollee" means an individual who is enrolled in a health

care plan, including covered dependents, as defined by Section

6592.1 of Title 36 of the Oklahoma Statutes;

7. "Health care provider" means any person or other entity who

is licensed pursuant to the provisions of Title 59 or Title 63 of

the Oklahoma Statutes, or pursuant to the definition in Section 1-

1708.1C of Title 63 of the Oklahoma Statutes;

8. "Health care services" means any services provided by a

health care provider, or by an individual working for or under the

supervision of a health care provider, that relate to the diagnosis,

assessment, prevention, treatment, or care of any human illness,

disease, injury, or condition, as defined by paragraph 2 of Section

1-1708.1C of Title 63 of the Oklahoma Statutes.

Oklahoma Statutes - Title 36. Insurance Page 1308

The term also includes the provision of mental health and substance

use disorder services, as defined by Section 6060.10 of Title 36 of

the Oklahoma Statutes, and the provision of durable medical

equipment. The term does not include the provision, administration,

or prescription of pharmaceutical products or services;

9. "Licensed mental health professional" means:

a. a psychiatrist who is a diplomate of the American

Board of Psychiatry and Neurology,

b. a psychiatrist who is a diplomate of the American

Osteopathic Board of Neurology and Psychiatry,
the provision of durable medical

equipment. The term does not include the provision, administration,

or prescription of pharmaceutical products or services;

9. "Licensed mental health professional" means:

a. a psychiatrist who is a diplomate of the American

Board of Psychiatry and Neurology,

b. a psychiatrist who is a diplomate of the American

Osteopathic Board of Neurology and Psychiatry,

c. a physician licensed pursuant to the Oklahoma

Allopathic Medical and Surgical Licensure and

Supervision Act or the Oklahoma Osteopathic Medicine

Act,

d. a clinical psychologist who is duly licensed to

practice by the State Board of Examiners of

Psychologists,

e. a professional counselor licensed pursuant to the

Licensed Professional Counselors Act,

f. a person licensed as a clinical social worker pursuant

to the provisions of the Social Worker's Licensing

Act,

g. a licensed marital and family therapist as defined in

the Marital and Family Therapist Licensure Act,

h. a licensed behavioral practitioner as defined in the

Licensed Behavioral Practitioner Act,

i. an advanced practice nurse as defined in the Oklahoma

Nursing Practice Act,

j. a physician assistant who is licensed in good standing

in this state, or

k. a licensed alcohol and drug counselor/mental health

(LADC/MH) as defined in the Licensed Alcohol and Drug

Counselors Act;

10. "Medically necessary" means services or supplies provided

by a health care provider that are:

a. appropriate for the symptoms and diagnosis or

treatment of the enrollee's condition, illness,

disease, or injury,

b. in accordance with standards of good medical practice,

c. not primarily for the convenience of the enrollee or

the enrollee's health care provider, and

d. the most appropriate supply or level of service that

can safely be provided to the enrollee as defined by

Section 6592 of Title 36 of the Oklahoma Statutes;

11. "Notice" means communication delivered either

electronically or through the United States Postal Service or common

carrier;

Oklahoma Statutes - Title 36. Insurance Page 1309

12. "Physician" means an allopathic or osteopathic physician

licensed by the State of Oklahoma or another state to practice

medicine;

13. "Prior authorization" means the process by which

utilization review entities determine the medical necessity and

medical appropriateness of otherwise covered health care services

prior to the rendering of such health care services. The term shall

include "authorization", "pre-certification", and any other term

that would be a reliable determination by a health benefit plan.

The term shall not be construed to include or refer to such

processes as they may pertain to pharmaceutical services;

14. "Urgent health care service" means a health care service

with respect to which the application of the time periods for making

an urgent care determination, which, in the opinion of a physician

with knowledge of the enrollee's medical condition:

a. could seriously jeopardize the life or health of the

enrollee or the ability of the enrollee to regain

maximum function, or

b. in the opinion of a physician with knowledge of the

claimant's medical condition, would subject the

enrollee to severe pain that cannot be adequately

managed without the care or treatment that is the

subject of the utilization review; and

15. "Utilization review entity" means an individual or entity

that performs prior authorization for a health benefit plan as

defined by Section 6060.4 of Title 36 of the Oklahoma Statutes, but

shall not include any health plan offered by a contracted entity

defined in Section 4002.2 of Title 56 of the Oklahoma Statutes that

provides coverage to members of the state Medicaid program or other

insurance subject to the Long-Term Care Insurance Act.