Requirements for processing and adjudicating claims.

1. Law
2. Oklahoma Statutes
3. Poor Persons
4. Requirements for processing and adjudicating claims.

A managed care organization or dental benefit manager shall comply with the following requirements with respect to processing and adjudication of claims for payment submitted in good faith by providers for health care items and services furnished by such providers to enrollees of the state Medicaid program:

1. A managed care organization or dental benefit manager shall process a clean claim in the time frame provided by Section 1219 of Title 36 of the Oklahoma Statutes and no less than ninety percent (90%) of all clean claims shall be paid within fourteen (14) days of submission to the managed care organization or dental benefit manager. A clean claim that is not processed within the time frame provided by Section 1219 of Title 36 of the Oklahoma Statutes shall bear simple interest at the monthly rate of one and one-half percent (1.5%) payable to the provider. A claim filed by a provider within six (6) months of the date the item or service was furnished to an enrollee shall be considered timely. If a claim meets the definition of a clean claim, the managed care organization or dental benefit manager shall not request medical records of the enrollee prior to paying the claim. Once a claim has been paid, the managed care organization or dental benefit manager may request medical records if additional documentation is needed to review the claim for medical necessity;

2. In the case of a denial of a claim including, but not limited to, a denial on the basis of the level of emergency care indicated on the claim, the managed care organization or dental benefit manager shall establish a process by which the provider may identify and provide such additional information as may be necessary to substantiate the claim. Any such claim denial shall include the following:

• a.a detailed explanation of the basis for the denial, and
• b.a detailed description of the additional information necessary to substantiate the claim;

3. Postpayment audits by a managed care organization or dental benefit manager shall be subject to the following requirements:

• a.subject to subparagraph b of this paragraph, insofar as a managed care organization or dental benefit manager conducts postpayment audits, the managed care organization or dental benefit manager shall employ the postpayment audit process determined by the Authority,
• b.the Authority shall establish a limit on the percentage of claims with respect to which postpayment audits may be conducted by a managed care organization or dental benefit manager for health care items and services furnished by a provider in a plan year, and
• c.the Authority shall provide for the imposition of financial penalties under such contract in the case of any managed care organization or dental benefit manager with respect to which the Authority determines has a claims denial error rate of greater than five percent (5%). The Authority shall establish the amount of financial penalties and the time frame under which such penalties shall be imposed on managed care organizations and dental benefit managers under this subparagraph, in no case less than annually; and

4. A managed care organization may only apply readmission penalties pursuant to rules promulgated by the Oklahoma Health Care Authority Board. The Board shall promulgate rules establishing a program to reduce potentially preventable readmissions. The program shall use a nationally recognized tool, establish a base measurement year and a performance year, and provide for risk-adjustment based on the population of the state Medicaid program covered by the managed care organizations and dental benefit managers.

Added by Laws 2021, c. 542, § 7, eff. Sept. 1, 2021.

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