External review procedure.

  1. Law
  2. Oklahoma Statutes
  3. Insurance
  4. External review procedure.

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A. 1. Except as provided in subsection B of this section, a request for an external review pursuant to Section 42, 43 or 44 of this act shall not be made until the covered person has exhausted the health carrier’s internal grievance process.

2. A covered person shall be considered to have exhausted the health carrier’s internal grievance process for purposes of this section, if the covered person or the covered person’s authorized representative:

  • a.has filed a grievance involving an adverse determination, and
  • b.except to the extent the covered person or the covered person’s authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within thirty (30) days following the date the covered person or the covered person’s authorized representative filed the grievance with the health carrier.

3. Notwithstanding paragraph 2 of this subsection, a covered person or the covered person’s authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to Sections 6551 through 6565 of Title 36 of the Oklahoma Statutes until the covered person has exhausted the health carrier’s internal grievance process.

  • B. 1. a.At the same time a covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination, the covered person or the covered person’s authorized representative may file a request for an expedited external review of the adverse determination:
    • (1)under Section 33 of this act if the covered person has a medical condition where the time frame for completion of an expedited review of the grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, or
    • (2)under Section 34 of this act if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.
  • b.Upon receipt of a request for an expedited external review under subparagraph a of this paragraph, the independent review organization conducting the external review in accordance with the provisions of Section 33 or 34 of this act shall determine whether the covered person shall be required to complete the expedited review process before it conducts the expedited external review.
  • c.Upon a determination made pursuant to subparagraph b of this paragraph that the covered person must first complete the expedited grievance review process, the independent review organization immediately shall notify the covered person and, if applicable, the covered person’s authorized representative of this determination and that it will not proceed with the expedited external review set forth in Section 33 of this act until completion of the expedited grievance review process and the covered person’s grievance at the completion of the expedited grievance review process remains unresolved.

2. A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier’s internal grievance procedures whenever the health carrier agrees to waive the exhaustion requirement.

C. If the requirement to exhaust the health carrier’s internal grievance procedures is waived under paragraph 2 of subsection B of this section, the covered person or the covered person’s authorized representative may file a request in writing for a standard external review as set forth in Section 32 or 34 of this act.

Added by Laws 2011, c. 278, § 41. Amended by Laws 2011, c. 360, § 31.


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