Oklahoma Utilization Review Regulations

Utilization review procedures in Oklahoma safeguard against unnecessary or inappropriate health care and services, inadequate quality of care, and inappropriate payment. According to the Oklahoma Health Care Authority Provider Billing and Procedure Manual, utilization review monitors billing and coding, level of care, medical necessity, documentation, misuse and overuse, prior authorization, and other administrative actions in the Oklahoma health care system.

Federal Regulations

• Title XIX of the Social Security Act mandates utilization review of Oklahoma Health Care Authority (OHCA) services. Federal regulations require OHCA to identify and refer suspected fraud or abuse cases to the Medicaid Fraud Control Unit of the state's attorney general.

Private Review Agents

• Adopted in 1991 by the State of Oklahoma, 36 O.S. § 6553 requires certification by the Insurance Commissioner before private agents can approve or deny benefit payments from utilization review. However, the State and Education Employees Group Insurance is exempt from such provisions.

In-House Utilization

• In-house utilization review for hospitals, preferred providers, home health agencies and other clinics, private offices and health facilities need not apply for certification under 36 O.S. § 6554. In-house utilization review is exempt from state regulations. This provision includes private review agents in connection with eligibility for federal and state hospital and medical services.

Privacy

• 36 O.S. § 6562 prohibits private review agents from disclosing or publishing individual medical records or information obtained during utilization review. In order to use information, proper procedures for patient confidentiality must be followed. However, private review agents may pass information to a third party to whom the agent is affiliated, under contract, or employed.

Fines

• The Insurance Commissioner of Oklahoma may subject a person or entity to a $100 to $1,000 fine for violation of the provisions of the Hospital and Medical Services Review Act under 36 O.S. § 6565.

Use of Oklahoma Physicians

• Oklahoma licensed physicians and health care professionals supervise the private review agent's utilization review activities, according to the Oklahoma Insurance Department. The physicians and professionals actively participate in the appeal and complaint process of the private review agent as set by Oklahoma law.

Uniform Claim Forms

• Oklahoma utilization review regulations set forth the implementation of uniform health care forms and uniform standards and procedures for claim processing. 36 O.S. § 6581 gives the Insurance Commissioner the authority to promulgate rules necessary for developing and administering a uniform claim form and processing system.