As used in this act:
1. "Adverse determination" has the same meaning as provided by Section 6475.3 of Title 36 of the Oklahoma Statutes;
2. "Claims denial error rate" means the rate of claims denials that are overturned on appeal;
3. "Clean claim" means a properly completed billing form with Current Procedural Terminology, 4th Edition or a more recent edition, the Tenth Revision of the International Classification of Diseases coding or a more recent revision, or Healthcare Common Procedure Coding System coding where applicable that contains information specifically required in the Provider Billing and Procedure Manual of the Oklahoma Health Care Authority;
4. "Dental benefit manager" means an entity under contract with the Oklahoma Health Care Authority to manage and deliver dental benefits and services to enrollees of the capitated managed care delivery model of the state Medicaid program;
5. "Essential community provider" has the same meaning as provided by 45 C.F.R., Section 156.235;
6. "Managed care organization" means a health plan under contract with the Oklahoma Health Care Authority to participate in and deliver benefits and services to enrollees of the capitated managed care delivery model of the state Medicaid program;
7. "Material change" includes, but is not limited to, any change in overall business operations such as policy, process or protocol which affects, or can reasonably be expected to affect, more than five percent (5%) of enrollees or participating providers of the managed care organization or dental benefit manager;
8. "Medical necessity" has the same meaning as provided by rules of the Oklahoma Health Care Authority Board;
9. "Participating provider" means a provider who has a contract with or is employed by a managed care organization or dental benefit manager to provide services to enrollees under the capitated managed care delivery model of the state Medicaid program; and
10. "Provider" means a health care or dental provider licensed or certified in this state.
Added by Laws 2021, c. 542, § 2, eff. Sept. 1, 2021.