Okla. Stat. tit. 36, § 36-6907

assurance plan and activities - Record of proceedings - Patient

record system - Medical policy - Credentialing and recredentialing

of health care providers - Termination or nonrenewal of contracts -

Emergency services.

A. Every health maintenance organization shall establish

procedures that ensure that health care services provided to

enrollees shall be rendered under reasonable standards of quality of

care consistent with prevailing professionally recognized standards

of medical practice. The procedures shall include mechanisms to

assure availability, accessibility and continuity of care.

B. The health maintenance organization shall have an ongoing

internal quality assurance program to monitor and evaluate its

health care services, including primary and specialist physician

services and ancillary and preventive health care services across

all institutional and noninstitutional settings. The program shall

include, but need not be limited to, the following:

1. A written statement of goals and objectives that emphasizes

improved health status in evaluating the quality of care rendered to

enrollees;

2. A written quality assurance plan that describes the

following:

a. the health maintenance organization's scope and

purpose in quality assurance,

b. the organizational structure responsible for quality

assurance activities,

c. contractual arrangements, where appropriate, for

delegation of quality assurance activities,

Oklahoma Statutes - Title 36. Insurance Page 1388

d. confidentiality policies and procedures,

e. a system of ongoing evaluation activities,

f. a system of focused evaluation activities,

g. a system for credentialing and recredentialing

providers, and performing peer review activities, and

h. duties and responsibilities of the designated

physician responsible for the quality assurance

activities;

3. A written statement describing the system of ongoing quality

assurance activities including:

a. problem assessment, identification, selection and

study,

b. corrective action, monitoring, evaluation and

reassessment, and

c. interpretation and analysis of patterns of care

rendered to individual patients by individual

providers;

4. A written statement describing the system of focused quality

assurance activities based on representative samples of the enrolled

population that identifies method of topic selection, study, data

collection, analysis, interpretation and report format; and

5. Written plans for taking appropriate corrective action

whenever, as determined by the quality assurance program,

inappropriate or substandard services have been provided or services

that should have been furnished have not been provided.

C. The organization shall record proceedings of formal quality

assurance program activities and maintain documentation in a

confidential manner. Quality assurance program minutes shall be

available to the Insurance Commissioner.

D. The organization shall ensure the use and maintenance of an

adequate patient record system which will facilitate documentation

and retrieval of clinical information for the purpose of the health

maintenance organization's evaluating continuity and coordination of

patient care and assessing the quality of health and medical care

provided to enrollees.

E. Enrollee clinical records shall be available to the

Insurance Commissioner or an authorized designee for examination and

review to ascertain compliance with this section, or as deemed

necessary by the Insurance Commissioner.

F. The organization shall establish a mechanism for periodic

reporting of quality assurance program activities to the governing

body, providers and appropriate organization staff.

G. The organization shall be required to establish a mechanism

under which physicians participating in the plan may provide input

into the plan's medical policy including, but not limited to,

coverage of new technology and procedures, utilization review
echanism for periodic

reporting of quality assurance program activities to the governing

body, providers and appropriate organization staff.

G. The organization shall be required to establish a mechanism

under which physicians participating in the plan may provide input

into the plan's medical policy including, but not limited to,

coverage of new technology and procedures, utilization review

Oklahoma Statutes - Title 36. Insurance Page 1389

criteria and procedures, quality, credentialing and recredentialing

criteria, and medical management procedures.

H. As used in this section "credentialing" or

"recredentialing", as applied to physicians and other health care

providers, means the process of accessing and validating the

qualifications of such persons to provide health care services to

the beneficiaries of a health maintenance organization.

Credentialing or recredentialing may include, but need not be

limited to, an evaluation of licensure status, education, training,

experience, competence and professional judgment. Credentialing or

recredentialing is a prerequisite to the final decision of a health

maintenance organization to permit initial or continued

participation by a physician or other health care provider.

1. Physician credentialing and recredentialing shall be based

on criteria as provided in the uniform credentialing application

required by Section 1-106.2 of Title 63 of the Oklahoma Statutes,

with input from physicians and other health care providers.

2. Organizations shall make information on credentialing and

recredentialing criteria available to physician applicants and other

health care providers, participating physicians, and other

participating health care providers and shall provide applicants

with a checklist of materials required in the application process.

3. When economic considerations are part of the credentialing

and recredentialing decision, objective criteria shall be used and

shall be available to physician applicants and participating

physicians. When graduate medical education is a consideration in

the credentialing and recredentialing process, equal recognition

shall be given to training programs accredited by the Accrediting

Council on Graduate Medical Education and by the American

Osteopathic Association. When graduate medical education is

considered for optometric physicians, consideration shall be given

for educational accreditation by the Council on Optometric

Education.

4. Physicians or other health care providers under

consideration to provide health care services under a managed care

plan in this state shall apply for credentialing and recredentialing

on the uniform credentialing application and provide the

documentation as outlined by the plan's checklist of materials

required in the application process.

5. A health maintenance organization (HMO) shall determine

whether a credentialing or recredentialing application is complete.

If an application is determined to be incomplete, the plan shall

notify the applicant in writing within ten (10) calendar days of

receipt of the application. The written notice shall specify the

portion of the application that is causing a delay in processing and

explain any additional information or corrections needed.

Oklahoma Statutes - Title 36. Insurance Page 1390

6. In reviewing the application, the health maintenance

organization (HMO) shall evaluate each application according to the

plan's checklist of materials required in the application process.

7. When an application is deemed complete, the HMO shall

initiate requests for primary source verification and malpractice

history within seven (7) calendar days.

8. A malpractice carrier shall have twenty-one (21) calendar

days within which to respond after receipt of an inquiry from a

health maintenance organization (HMO). Any malpractice carrier that

fails to respond to an inquiry within the allotted time frame may be
ed complete, the HMO shall

initiate requests for primary source verification and malpractice

history within seven (7) calendar days.

8. A malpractice carrier shall have twenty-one (21) calendar

days within which to respond after receipt of an inquiry from a

health maintenance organization (HMO). Any malpractice carrier that

fails to respond to an inquiry within the allotted time frame may be

assessed an administrative penalty by the Insurance Commissioner.

9. Upon receipt of primary source verification and malpractice

history by the HMO, the HMO shall determine if the application is a

clean application. If the application is deemed clean, the HMO

shall have forty-five (45) calendar days within which to credential

or recredential a physician or other health care provider. As used

in this paragraph, "clean application" means an application that has

no defect, misstatement of facts, improprieties, including a lack of

any required substantiating documentation, or particular

circumstance requiring special treatment that impedes prompt

credentialing or recredentialing.

10. If a health maintenance organization is unable to

credential or recredential a physician or other health care provider

due to an application's not being clean, the HMO may extend the

credentialing or recredentialing process for sixty (60) calendar

days. At the end of sixty (60) calendar days, if the HMO is

awaiting documentation to complete the application, the physician or

other health care provider shall be notified of the delay by

certified mail. The physician or other health care provider may

extend the sixty-day period upon written notice to the HMO within

ten (10) calendar days; otherwise the application shall be deemed

withdrawn.

11. In no event shall the entire credentialing or

recredentialing process exceed one hundred eighty (180) calendar

days.

12. A health maintenance organization shall be prohibited from

solely basing a denial of an application for credentialing or

recredentialing on the lack of board certification or board

eligibility and from adding new requirements solely for the purpose

of delaying an application.

13. Any HMO that violates the provisions of this subsection may

be assessed an administrative penalty by the Insurance Commissioner.

I. Health maintenance organizations shall not discriminate

against enrollees with expensive medical conditions by excluding

practitioners with practices containing a substantial number of

these patients.

Oklahoma Statutes - Title 36. Insurance Page 1391

J. Health maintenance organizations shall, upon request,

provide to a physician whose contract is terminated or not renewed

for cause the reasons for termination or nonrenewal. Health

maintenance organizations shall not contractually prohibit such

requests.

K. No HMO shall engage in the practice of medicine or any other

profession except as provided by law nor shall an HMO include any

provision in a provider contract that precludes or discourages a

health maintenance organization's providers from:

1. Informing a patient of the care the patient requires,

including treatments or services not provided or reimbursed under

the patient's HMO; or

2. Advocating on behalf of a patient before the HMO.

L. Decisions by a health maintenance organization to authorize

or deny coverage for an emergency service shall be based on the

patient presenting symptoms arising from any injury, illness, or

condition manifesting itself by acute symptoms of sufficient

severity, including severe pain, such that a reasonable and prudent

layperson could expect the absence of medical attention to result in

serious:

1. Jeopardy to the health of the patient;

2. Impairment of bodily function; or

3. Dysfunction of any bodily organ or part.

M. Health maintenance organizations shall not deny an otherwise

covered emergency service based solely upon lack of notification to

the HMO.
ng severe pain, such that a reasonable and prudent

layperson could expect the absence of medical attention to result in

serious:

1. Jeopardy to the health of the patient;

2. Impairment of bodily function; or

3. Dysfunction of any bodily organ or part.

M. Health maintenance organizations shall not deny an otherwise

covered emergency service based solely upon lack of notification to

the HMO.

N. Health maintenance organizations shall compensate a provider

for patient screening, evaluation, and examination services that are

reasonably calculated to assist the provider in determining whether

the condition of the patient requires emergency service. If the

provider determines that the patient does not require emergency

service, coverage for services rendered subsequent to that

determination shall be governed by the HMO contract.

O. If within a period of thirty (30) minutes after receiving a

request from a hospital emergency department for a specialty

consultation, a health maintenance organization fails to identify an

appropriate specialist who is available and willing to assume the

care of the enrollee, the emergency department may arrange for

emergency services by an appropriate specialist that are medically

necessary to attain stabilization of an emergency medical condition,

and the HMO shall not deny coverage for the services due to lack of

prior authorization.

P. The reimbursement policies and patient transfer requirements

of a health maintenance organization shall not, directly or

indirectly, require a hospital emergency department or provider to

violate the federal Emergency Medical Treatment and Active Labor

Act. If a member of an HMO is transferred from a hospital emergency

Oklahoma Statutes - Title 36. Insurance Page 1392

department facility to another medical facility, the HMO shall

reimburse the transferring facility and provider for services

provided to attain stabilization of the emergency medical condition

of the member in accordance with the federal Emergency Medical

Treatment and Active Labor Act.