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1 STATE OF OKLAHOMA
2 1st Session of the 60th Legislature (2025)
3 HOUSE BILL 1810 By: Newton
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6 AS INTRODUCED
7 An Act relating to prior authorization; amending
Section 2, Chapter 303, O.S.L. 2024 (36 O.S. Supp.
8 2024, Section 6570.1), which relates to definitions;
modifying a definition; amending 56 O.S. 2021,
9 Section 4002.6, as last amended by Section 5, Chapter
448, O.S.L. 2024 (56 O.S. Supp. 2024, Section
10 4002.6), which relates to prior authorizations, other
authorization requests, and requirements; modifying
11 standard for requirements; removing certain
requirements; and providing an effective date.
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14 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
15 SECTION 1. AMENDATORY Section 2, Chapter 303, O.S.L.
16 2024 (36 O.S. Supp. 2024, Section 6570.1), is amended to read as
17 follows:
18 Section 6570.1. As used in this act:
19 1. "Adverse determination" means a determination by a health
20 carrier or its designee utilization review entity that an admission,
21 availability of care, continued stay, or other health care service
22 that is a covered benefit has been reviewed and, based upon the
23 information provided, does not meet the health carrier's
24 requirements for medical necessity, appropriateness, health care
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1 setting, level of care, or effectiveness, and the requested service
2 or payment for the service is therefore denied, reduced, or
3 terminated as defined by Section 6475.3 of Title 36 of the Oklahoma
4 Statutes;
5 2. "Chronic condition" means a condition that lasts one (1)
6 year or more and requires ongoing medical attention or limits
7 activities of daily living or both;
8 3. "Clinical criteria" means the written policies, written
9 screening procedures, determination rules, determination abstracts,
10 clinical protocols, practice guidelines, medical protocols, and any
11 other criteria or rationale used by the utilization review entity to
12 determine the necessity and appropriateness of health care services;
13 4. "Emergency health care services", with respect to an
14 emergency medical condition as defined in 42 U.S.C.A., Section
15 300gg-111, means:
16 a. a medical screening examination, as required under
17 Section 1867 of the Social Security Act, 42 U.S.C.,
18 Section 1395dd, or as would be required under such
19 section if such section applied to an independent,
20 freestanding emergency department, that is within the
21 capability of the emergency department of a hospital
22 or of an independent, freestanding emergency
23 department, as applicable, including ancillary
24 services routinely available to the emergency
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1 department to evaluate such emergency medical
2 condition, and
3 b. within the capabilities of the staff and facilities
4 available at the hospital or the independent,
5 freestanding emergency department, as applicable, such
6 further medical examination and treatment as are
7 required under Section 1395dd of the Social Security
8 Act, or as would be required under such section if
9 such section applied to an independent, freestanding
10 emergency department, to stabilize the patient,
11 regardless of the department of the hospital in which
12 such further examination or treatment is furnished, as
13 defined by 42 U.S.C.A., Section 300gg-111;
14 5. "Emergency Medical Treatment and Active Labor Act" or
15 "EMTALA" means Section 1867 of the Social Security Act and
16 associated regulations;
17 6. "Enrollee" means an individual who is enrolled in a health
18 care plan, including covered dependents, as defined by Section
19 6592.1 6592 of Title 36 of the Oklahoma Statutes;
20 7. "Health care provider" means any person or other entity who
21 is licensed pursuant to the provisions of Title 59 or Title 63 of
22 the Oklahoma Statutes, or pursuant to the definition in Section 1-
23 1708.1C of Title 63 of the Oklahoma Statutes;
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1 8. "Health care services" means any services provided by a
2 health care provider, or by an individual working for or under the
3 supervision of a health care provider, that relate to the diagnosis,
4 assessment, prevention, treatment, or care of any human illness,
5 disease, injury, or condition, as defined by paragraph 2 of Section
6 1-1708.1C of Title 63 of the Oklahoma Statutes.
7 The term also includes the provision of mental health and substance
8 use disorder services, as defined by Section 6060.10 of Title 36 of
9 the Oklahoma Statutes, and the provision of durable medical
10 equipment. The term does not include the provision, administration,
11 or prescription of pharmaceutical products or services;
12 9. "Licensed mental health professional" means:
13 a. a psychiatrist who is a diplomate of the American
14 Board of Psychiatry and Neurology,
15 b. a psychiatrist who is a diplomate of the American
16 Osteopathic Board of Neurology and Psychiatry,
17 c. a physician licensed pursuant to the Oklahoma
18 Allopathic Medical and Surgical Licensure and
19 Supervision Act or the Oklahoma Osteopathic Medicine
20 Act,
21 d. a clinical psychologist who is duly licensed to
22 practice by the State Board of Examiners of
23 Psychologists,
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1 e. a professional counselor licensed pursuant to the
2 Licensed Professional Counselors Act,
3 f. a person licensed as a clinical social worker pursuant
4 to the provisions of the Social Worker's Licensing
5 Act,
6 g. a licensed marital and family therapist as defined in
7 the Marital and Family Therapist Licensure Act,
8 h. a licensed behavioral practitioner as defined in the
9 Licensed Behavioral Practitioner Act,
10 i. an advanced practice nurse as defined in the Oklahoma
11 Nursing Practice Act,
12 j. a physician assistant who is licensed in good standing
13 in this state, or
14 k. a licensed alcohol and drug counselor/mental health
15 (LADC/MH) as defined in the Licensed Alcohol and Drug
16 Counselors Act;
17 10. "Medically necessary" means services or supplies provided
18 by a health care provider that are:
19 a. appropriate for the symptoms and diagnosis or
20 treatment of the enrollee's condition, illness,
21 disease, or injury,
22 b. in accordance with standards of good medical practice,
23 c. not primarily for the convenience of the enrollee or
24 the enrollee's health care provider, and
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1 d. the most appropriate supply or level of service that
2 can safely be provided to the enrollee as defined by
3 Section 6592 of Title 36 of the Oklahoma Statutes;
4 11. "Notice" means communication delivered either
5 electronically or through the United States Postal Service or common
6 carrier;
7 12. "Physician" means an allopathic or osteopathic physician
8 licensed by the State of Oklahoma or another state to practice
9 medicine;
10 13. "Prior authorization" means the process by which
11 utilization review entities determine the medical necessity and
12 medical appropriateness of otherwise covered health care services
13 prior to the rendering of such health care services. The term shall
14 include "authorization", "pre-certification", and any other term
15 that would be a reliable determination by a health benefit plan.
16 The term shall not be construed to include or refer to such
17 processes as they may pertain to pharmaceutical services;
18 14. "Urgent health care service" means a health care service
19 with respect to which the application of the time periods for making
20 an urgent care determination, which, in the opinion of a physician
21 with knowledge of the enrollee's medical condition:
22 a. could seriously jeopardize the life or health of the
23 enrollee or the ability of the enrollee to regain
24 maximum function, or
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1 b. in the opinion of a physician with knowledge of the
2 claimant's medical condition, would subject the
3 enrollee to severe pain that cannot be adequately
4 managed without the care or treatment that is the
5 subject of the utilization review; and
6 15. "Utilization review entity" means an individual or entity
7 that performs prior authorization for a health benefit plan as
8 defined by Section 6060.4 of Title 36 of the Oklahoma Statutes, but
9 shall not include any health plan offered by a contracted entity
10 defined in Section 4002.2 of Title 56 of the Oklahoma Statutes that
11 provides coverage to members of the state Medicaid program or other
12 insurance subject to the Long-Term Care Insurance Act.
13 SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.6, as
14 last amended by Section 5, Chapter 448, O.S.L. 2024 (56 O.S. Supp.
15 2024, Section 4002.6), is amended to read as follows:
16 Section 4002.6. A. A contracted entity shall meet all
17 requirements established by the Oklahoma Health Care Authority
18 pertaining to prior authorizations, all requirements shall align
19 with the provisions of the Ensuring Transparency in Prior
20 Authorization Act in Sections 6570.1 through 6570.11 of Title 36 of
21 the Oklahoma Statutes. The Authority shall establish requirements
22 that ensure timely determinations by contracted entities when prior
23 authorizations are required including expedited review in urgent and
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1 emergent cases that at a minimum meet the criteria of this section,
2 and the Ensuring Transparency in Prior Authorization Act.
3 B. A contracted entity shall make a determination on a request
4 for an authorization of the transfer of a hospital inpatient to a
5 post-acute care or long-term acute care facility within twenty-four
6 (24) hours of receipt of the request.
7 C. A contracted entity shall make a determination on a request
8 for any member who is not hospitalized at the time of the request
9 within seventy-two (72) hours of receipt of the request; provided,
10 that if the request does not include sufficient or adequate
11 documentation, the review and determination shall occur within a
12 time frame and in accordance with a process established by the
13 Authority. The process established by the Authority pursuant to
14 this subsection shall include a time frame of at least forty-eight
15 (48) hours within which a provider may submit the necessary
16 documentation.
17 D. A contracted entity shall make a determination on a request
18 for services for a hospitalized member including, but not limited
19 to, acute care inpatient services or equipment necessary to
20 discharge the member from an inpatient facility within twenty-four
21 (24) hours of receipt of the request.
22 E. Notwithstanding the provisions of subsection C of this
23 section, a contracted entity shall make a determination on a request
24 as expeditiously as necessary and, in any event, within twenty-four
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1 (24) hours of receipt of the request for service if adhering to the
2 provisions of subsection C or D of this section could jeopardize the
3 member's life, health or ability to attain, maintain or regain
4 maximum function. In the event of a medically emergent matter, the
5 contracted entity shall not impose limitations on providers in
6 coordination of post-emergent stabilization health care including
7 pre-certification or prior authorization.
8 F. Notwithstanding any other provision of this section, a
9 contracted entity shall make a determination on a request for
10 inpatient behavioral health services within twenty-four (24) hours
11 of receipt of the request.
12 G. A contracted entity shall make a determination on a request
13 for covered prescription drugs that are required to be prior
14 authorized by the Authority within twenty-four (24) hours of receipt
15 of the request. The contracted entity shall not require prior
16 authorization on any covered prescription drug for which the
17 Authority does not require prior authorization.
18 H. C. A contracted entity shall make a determination on a
19 request for coverage of biomarker testing in accordance with Section
20 4003 of this title.
21 I. Upon issuance of an adverse determination on a prior
22 authorization request under subsection B of this section, the
23 contracted entity shall provide the requesting provider, within
24 seventy-two (72) hours of receipt of such issuance, with reasonable
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1 opportunity to participate in a peer-to-peer review process with a
2 provider who practices in the same specialty, but not necessarily
3 the same sub-specialty, and who has experience treating the same
4 population as the patient on whose behalf the request is submitted;
5 provided, however, if the requesting provider determines the
6 services to be clinically urgent, the contracted entity shall
7 provide such opportunity within twenty-four (24) hours of receipt of
8 such issuance. Services not covered under the state Medicaid
9 program for the particular patient shall not be subject to peer-to-
10 peer review.
11 J. The Authority shall ensure that a provider offers to provide
12 to a member in a timely manner services authorized by a contracted
13 entity.
14 K. The Authority shall establish requirements for both internal
15 and external reviews and appeals of adverse determinations on prior
16 authorization requests or claims that, at a minimum:
17 1. Require contracted entities to provide a detailed
18 explanation of denials to Medicaid providers and members;
19 2. Require contracted entities to provide an opportunity for
20 peer-to-peer conversations with Oklahoma-licensed clinical staff of
21 the same or similar specialty within twenty-four (24) hours of the
22 adverse determination; and
23 3. Establish uniform rules for Medicaid provider or member
24 appeals across all contracted entities.
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1 SECTION 3. This act shall become effective November 1, 2025.
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3 60-1-10616 TJ 12/16/24
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Req. No. 10616 Page 11Every fact on this page links to its source, starting with the official bill record.