Shown verbatim: the complete text as captured from the official PDF posted by the Oklahoma Legislature, fetched 2026-07-23. Page and line markers are part of the official record; nothing is edited or removed. The official bill page.
1 STATE OF OKLAHOMA
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2 2nd Session of the 60th Legislature (2026)
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3 SENATE BILL 1553 By: Rosino
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6 AS INTRODUCED
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7 An Act relating to the state Medicaid program;
7 amending 56 O.S. 2021, Section 4002.8, as last
8 amended by Section 3, Chapter 372, O.S.L. 2025 (56
8 O.S. Supp. 2025, Section 4002.8), which relates to
9 review and appeal of adverse determinations;
9 specifying qualifications for psychologist reviewing
10 appeal; providing for recovery of certain costs;
10 updating statutory language; and providing an
11 effective date.
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14 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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15 SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.8, as
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16 last amended by Section 3, Chapter 372, O.S.L. 2025 (56 O.S. Supp.
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17 2025, Section 4002.8), is amended to read as follows:
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18 Section 4002.8. A. A contracted entity shall utilize uniform
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19 procedures established by the Oklahoma Health Care Authority under
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20 subsection B of this section for the review and appeal of any
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21 adverse determination by the contracted entity sought by any member
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22 or provider adversely affected by such determination.
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1 B. The Authority shall develop procedures for members or
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2 providers to seek review by the contracted entity of any adverse
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3 determination made by the contracted entity.
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4 C. A provider shall have six (6) months from the receipt of a
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5 claim denial to file an appeal.
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6 D. A contracted entity shall ensure that all appeals of adverse
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7 determinations made by the contracted entity are reviewed by a
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8 licensed physician or, if appropriate for the requested service, a
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9 licensed psychologist or mental health professional. The contracted
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10 entity shall not use any automated claim review software or other
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11 automated functionality for such appeals.
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12 E. The physician, psychologist, or other mental health
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13 professional who reviews the appeal shall:
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14 1. Possess a current and valid unrestricted license in any
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15 United States jurisdiction;
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16 2. Be of the same or similar specialty as a physician,
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17 psychologist, or other mental health professional who typically
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18 manages the medical condition or disease. This requirement shall be
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19 considered met:
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20 a. for a physician, if:
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21 (1) the physician maintains board certification for
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22 the same or similar specialty as the medical
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23 condition in question, or
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24 (2) the physician's training and experience:
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Req. No. 3185 Page 2
1 (a) includes treatment of the condition,
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2 (b) includes treatment of complications that may
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3 result from the service or procedure, and
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4 (c) is sufficient for the physician to determine
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5 if the service or procedure is medically
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6 necessary or clinically appropriate, or
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7 b. for a psychologist, if:
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8 (1) the psychologist is currently licensed in
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9 accordance with the Psychologists Licensing Act,
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10 (2) the psychologist has training and experience in
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11 the testing for and treatment of the condition,
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12 and
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13 (3) the psychologist's training and experience is
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14 sufficient to determine if the service is
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15 medically necessary or clinically appropriate, or
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16 c. for a mental health professional other than a
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17 psychologist, if the mental health professional's
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18 training and experience:
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19 (1) includes treatment of the condition, and
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20 (2) is sufficient for the mental health professional
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21 to determine if the service is medically
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22 necessary or clinically appropriate;
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23 3. Not have been directly involved in making the adverse
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24 determination;
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Req. No. 3185 Page 3
1 4. Not have any financial interest in the outcome of the
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2 appeal; and
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3 5. Consider all known clinical aspects of the health care
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4 service under review including, but not limited to, a review of any
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5 medical records pertinent to the active condition that are provided
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6 to the contracted entity by the member's provider, or a health care
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7 facility, and any pertinent medical literature provided to the
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8 contracted entity by the provider.
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9 F. 1. Upon receipt of notice from the contracted entity that
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10 the adverse determination has been upheld on appeal, the member or
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11 provider may request a fair hearing from the Authority. The
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12 Authority shall develop procedures for fair hearings in accordance
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13 with 42 C.F.R., Part 431.
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14 2. Such procedures shall provide for the recovery of costs by a
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15 psychologist or other mental health provider from the contracted
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16 entity for time and expenses related to the appeal if the adverse
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17 determination of the contracted entity is reversed through the fair
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18 hearing. The procedures for calculation of such costs shall take
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19 into account the time spent by the psychologist or other mental
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20 health provider on the administration of the appeal that would have
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21 otherwise been spent providing services to patients.
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22 SECTION 2. This act shall become effective November 1, 2026.
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24 60-2-3185 DC 1/12/2026 6:03:37 PM
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Req. No. 3185 Page 4Every fact on this page links to its source, starting with the official bill record.