Oklahoma Administrative Code
Title 310 - Oklahoma State Department of Health
Chapter 657 - Certified Workplace Medical Plans
Subchapter 7 - Utilization Review
Section 310:657-7-2 - Scope and content of utilization review
Universal Citation: OK Admin Code 310:657-7-2
Current through Vol. 42, No. 1, September 16, 2024
(a) The Plan shall implement a utilization review program that describes all delegated and nondelegated review activities for covered services. The program shall include:
(1) Procedures to evaluate service need,
appropriateness and efficiency, with processes to detect service underuse and
overuse;
(2) Data sources and
review criteria used to determine the need for, and appropriateness of, medical
and health services;
(3) Processes
for resolving disputes on medical or health services;
(4) Consistent application of criteria and
decisions;
(5) Data collection and
analytical methods that may be used to assess use of health care
services;
(6) Provisions for
ensuring confidentiality of information;
(7) Reports to the governing body or its
designee; and
(8) Day-to-day
program management.
(b) The Plan shall file with the Commissioner an annual report summarizing utilization review activities. The data shall preserve the confidentiality of information about individual workers. The Commissioner may request additional information based on material in the report.
Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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