Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 2 - Grievance Procedures and Process
Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect
Section 317:2-3-6 - External medical review and clinical expertise
Universal Citation: OK Admin Code 317:2-3-6
Current through Vol. 41, No. 13, March 15, 2024
(a) No external medical review. The Oklahoma Health Care Authority (OHCA) will not offer an external medical review for the purposes of grievances or appeals.
(b) Clinical expertise standards. Individuals making the decision for a grievance or appeal regarding an adverse benefit determination will be unbiased with appropriate clinical expertise in treating the member's condition or disease.
(1) Medical review staff of the MCE will be
licensed or credentialed health care clinicians with relevant clinical training
and/or experience.
(2) All MCEs
will use medical review staff for such appeals and shall not use any automated
claim review software or other automated functionality for such
appeals.
(3) Bias is deemed to
exist if an individual making a decision on a grievance or appeal was involved
in, or a subordinate of any individual involved in, any previous level of
review or decision regarding the subject matter of the grievance or
appeal.
(4) Clinical expertise is
deemed necessary for decisions makers whenever:
(A) The denial is based on a lack of medical
necessity;
(B) The grievance is
regarding a denial of an expedited resolution an appeal; and
(C) The grievance or appeal involves clinical
issues.
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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