A. The Oklahoma Health Care Authority shall establish requirements for fair processing and adjudication of claims that ensure prompt reimbursement of providers by contracted entities. A contracted entity shall comply with all such requirements. B. A contracted entity 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 contracted entity. 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 a member shall be considered timely. If a claim meets the definition of a clean claim, the contracted entity shall not request medical records of the member prior to paying the claim. Once a claim has been paid, the contracted entity may request medical records if additional documentation is needed to review the claim for medical necessity. C. 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, or in the case of a downcoded claim, the contracted entity 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 or downcode shall include the following: 1. A detailed explanation of the basis for the denial; and 2. A detailed description of the additional information necessary to substantiate the claim. D. Postpayment audits by a contracted entity shall be subject to the following requirements: 1. Subject to paragraph 2 of this subsection, insofar as a contracted entity conducts postpayment audits, the contracted entity shall employ the postpayment audit process determined by the Authority; 2. The Authority shall establish a limit on the percentage of claims with respect to which postpayment audits may be conducted by a contracted entity for health care items and services furnished by a provider in a plan year; and 3. The Authority shall provide for the imposition of financial penalties under such contract in the case of any contracted entity 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 contracted entities under this paragraph, in no case less than annually. E. A contracted entity 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 contracted entities.
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