A. A contracted entity shall meet all requirements established by this section pertaining to prior authorizations. To the extent a contracted entity uses a third-party utilization review entity to administer prior authorizations on its behalf, the utilization review entity shall comply with the provisions of this section applicable to contracted entities. B. 1. A contracted entity shall make any current prior authorization requirements and restrictions, including written clinical criteria, readily accessible on its website to members and participating providers. Such requirements and restrictions shall be described in detail but also in easily understandable language. 2. If a contracted entity intends either to implement a new prior authorization requirement or restriction or to amend an existing requirement or restriction, the contracted entity shall: a. ensure that the new or amended requirement or restriction is not implemented until the contracted entity’s website has been updated to reflect the new or amended requirement or restriction, and b. provide participating providers credentialed to perform the service, and members who have a chronic condition and are already receiving the service which the prior authorization changes will impact, notice of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented. C. A contracted entity shall ensure that all adverse determinations are made by a licensed physician or, if appropriate for the requested service, a licensed mental health professional. The physician or mental health professional shall: 1. Possess a current and valid nonrestricted license in any United States jurisdiction; 2. Have the appropriate training, knowledge, or expertise to apply appropriate clinical guidelines to the health care service being requested; and 3. Make the adverse determination under the clinical direction of a medical director of the contracted entity who is responsible for reviewing health care services to members. Any such medical director shall be a physician licensed in any United States jurisdiction. D. 1. Not later than January 1, 2027, each contracted entity shall implement and maintain a Prior Authorization Application Programming Interface (API), as described in 45 C.F.R., Part 156. 2. Not later than July 1, 2027, all participating providers shall have electronic health records or practice management systems that are compatible with the API, subject to such exceptions as may be authorized by the Oklahoma Health Care Authority Board through rule. E. 1. If a contracted entity or the Authority requires prior authorization of a health care service, the contracted entity shall make a prior authorization or adverse determination in accordance with the following time periods: a. for urgent health care services, within seventy-two (72) hours of obtaining all necessary information to make the prior authorization or adverse determination, b. for non-urgent health care services, within seven (7) days of obtaining all necessary information to make the prior authorization or adverse determination, c. for covered prescription drugs, within twenty-four (24) hours of obtaining all necessary information to make the prior authorization or adverse determination. The contracted entity shall not require prior authorization on any covered prescription drug for which the Authority does not require prior authorization, and d. for coverage of biomarker testing, in accordance with Section 4003 of this title. 2. If a participating provider submits all necessary information through the contracted entity’s authorized prior authorization system, and if the contracted entity fails to comply with the deadlines specified in this subsection, such health care services are deemed authorized. 3. For the purposes of this subsection, “necessary information” includes, but is not limited to, the results of any face-to-face clinical evaluation or second opinion that may be required. F. 1. If a member needs emergency health care services, the member’s contracted entity shall not require prior authorization for pre-hospital transportation, for the provision of emergency health care services, or for transfers between facilities as required by the federal Emergency Medical Treatment and Labor Act. 2. A contracted entity shall allow a member and the member’s provider a minimum of twenty-four (24) hours following an emergency admission or provision of emergency health care services for the member or provider to notify the contracted entity of the admission or provision of health care services. If the admission or health care service occurs on a holiday or weekend, the contracted entity shall not require notification until the next business day after the admission or provision of the health care services. G. 1. In the notification to the provider that a prior authorization has been approved, the contracted entity shall include in such notification the duration of the prior authorization or the date by which the prior authorization will expire. 2. A contracted entity shall not revoke, limit, condition, or restrict a prior authorization if the authorized service is provided within forty-five (45) business days from the date the provider received the prior authorization unless the member was no longer eligible for the service on the date it was provided. 3. On receipt of information documenting a prior authorization from the member or from the member’s provider, a contracted entity shall honor a prior authorization granted to a member from a previous contracted entity for at least the initial sixty (60) days of a member’s coverage under a new contracted entity. During the time period described in this subsection, a contracted entity may perform its own review to grant a prior authorization or make an adverse determination. H. A contracted entity shall provide participating providers with the following opportunities for communication during the prior authorization process: 1. Make staff available at least eight (8) hours each day during normal business hours for inbound telephone calls regarding prior authorization issues; 2. Allow staff to receive inbound communication regarding prior authorization issues after normal business hours; and 3. Provide a participating provider with the opportunity to discuss a prior authorization denial with an appropriate reviewer. I. A contracted entity shall reimburse a participating provider at the contracted payment rate for a health care service provided by the provider per a prior authorization, subject to any applicable reimbursement requirements provided by Section 4002.12 of this title, unless: 1. The provider knowingly and materially misrepresented the health care service in the prior authorization request with the specific intent to deceive and obtain an unlawful payment from a contracted entity; 2. The health care service was no longer a covered benefit on the day it was provided; 3. The provider was no longer contracted with the member’s contracted entity on the date the service was provided; 4. The provider failed to meet the contracted entity’s timely filing requirements; or 5. The member was no longer eligible for health care coverage on the date the service was provided. Added by Laws 2021, c. 542, § 6, eff. Sept. 1, 2021. Amended by Laws 2022, c. 395, § 10, eff. July 1, 2022; Laws 2023, c. 331, § 2, eff. Jan. 1, 2024; Laws 2024, c. 448, § 5, emerg. eff. June 14, 2024; Laws 2025, c. 372, § 2, eff. Nov. 1, 2025.
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