1| STATE OF OKLAHOMA | | | 2| 2nd Session of the 60th Legislature (2026) | | | 3|HOUSE BILL 4462 By: Newton | | | 4| | | | 5| | | | 6| AS INTRODUCED | | | 7| An Act relating to health insurance; providing | | definitions; establishing that non-urgent care prior | 8| authorization requests shall be deemed approved if | | the utilization review organization fails to take | 9| certain action; granting the utilization review | | organization additional time for decision if network | 10| provider is requested to provide additional | | information; providing requirements for additional | 11| information requests; requiring network provider to | | submit new prior authorization request if they fail | 12| to provide all clinical information; requiring | | network providers to submit non-urgent care requests | 13| at least six days before scheduled health care | | service; establishing that urgent care prior | 14| authorization requests shall be deemed approved if | | the utilization review organization fails to take | 15| certain action; requiring network provider to submit | | additional information within twenty four hours of | 16| receiving request; directing utilization review | | organizations to ensure requests for prior | 17| authorization are made by physician or other | | competent health care professional; requiring | 18| utilization review organizations to include certain | | information with notice of adverse determination; | 19| requiring utilization review organizations to ensure | | adverse determinations are made by qualified | 20| physicians; directing utilization review | | organizations to make appeals process readily | 21| accessible on website; requiring response to appeals | | within certain timeframe; requiring appeals to be | 22| decided by physician other than physician who made | | original adverse determination; directing insurers to | 23| exempt certain network providers from obtaining prior | | authorization for covered health care services; | 24| clarifying that exemption shall be effective for | | succeeding year upon determination by utilization | Req. No. 14146 Page 1 ___________________________________________________________________________
1| review organization; permitting insurers to rescind | | exemption for certain actions by health care | 2| professional; permitting insurers to automatically | | renew exemption if certain conditions are met; | 3| directing insurers to make written notice of a | | decision granting or declining renewal of an | 4| exemption; providing required contents for notice of | | rescission or declination of exemption; requiring | 5| insurer afford a health care professional reasonable | | opportunity to challenge grounds for a decision; | 6| directing for reconsideration to be performed by | | qualified physician; clarifying decision on | 7| reconsideration is final; requiring information be | | held in strictest confidence; clarifying health care | 8| professional whose exemption was rescinded or not | | renewed for certain reasons remains automatically | 9| eligible for an exemption; establishing that these | | exemptions do not apply to experimental health care | 10| services; granting the Oklahoma Insurance | | Commissioner rule making authority; providing for | 11| codification; and providing an effective date. | | | 12| | | | 13| | | | 14|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 15| SECTION 1. NEW LAW A new section of law to be codified | | | 16|in the Oklahoma Statutes as Section 6567.1 of Title 36, unless there | | | 17|is created a duplication in numbering, reads as follows: | | | 18| As used in this act: | | | 19| 1. "Additional business day" means the first weekday not | | | 20|designated as a state or federal holiday; | | | 21| 2. "Adverse determination" means a determination by a | | | 22|utilization review organization that a request for coverage of a | | | 23|benefit under a health benefit plan does not meet the insurer's | | | 24|policies or guidelines for medical necessity or appropriateness, | | | Req. No. 14146 Page 2 ___________________________________________________________________________
1|including treatment setting, level of care, or effectiveness. The | | | 2|term includes a denial, reduction, termination, or modification of | | | 3|the benefit requested or payment therefor; | | | 4| 3. "Artificial intelligence" means a machine-based system that | | | 5|may include software or physical hardware that performs tasks, based | | | 6|upon data set inputs, which requires human-like perception, | | | 7|cognition, planning, learning, communication, or physical action and | | | 8|which is capable of improving performance based upon learned | | | 9|experience without significant human oversight toward influencing | | | 10|real or virtual environments; | | | 11| 4. "Enrollee" means an individual who contracts for, | | | 12|subscribes, or participates as a dependent under a health benefit | | | 13|plan; | | | 14| 5. "Health benefit plan" means: | | | 15| a. any plan, policy, or contract issued, delivered, or | | | 16| renewed in this state that provides medical benefits | | | 17| that include payment or reimbursement for | | | 18| hospitalization, physician care, treatment, surgery, | | | 19| therapy, drugs, equipment, and other medical expenses, | | | 20| regardless of whether the plan is for a group or an | | | 21| individual, and | | | 22| b. the term does not include accident-only, specified | | | 23| disease, individual hospital indemnity, credit, | | | 24| dental-only, Medicare supplement, long-term care, | | | Req. No. 14146 Page 3 ___________________________________________________________________________
1| disability income, or other limited benefit health | | | 2| insurance policies, or coverage issued as supplemental | | | 3| to liability insurance, workers' compensation, or | | | 4| automobile medical payment insurance; | | | 5| 6. "Health care professional" means a physician or other health | | | 6|care provider who is licensed by an occupational licensing board | | | 7|under Title 59 or Title 63 of the Oklahoma Statutes. | | | 8| 7. "Health care service" means diagnosing, testing, monitoring, | | | 9|or treating a human disease, disorder, syndrome, or illness that may | | | 10|include, but not be limited to, hospitalization, physician care, | | | 11|treatment, surgery, therapy, drugs, or medical equipment; | | | 12| 8. "Insurer" means any entity that issues, delivers, or renews | | | 13|a health benefit plan, a health maintenance organization, or a | | | 14|nonprofit health care service; | | | 15| 9. "Medical necessity" means the question of whether a health | | | 16|care service is medically necessary; | | | 17| 10. "Network providers" means facilities and health care | | | 18|professionals who, pursuant to a contract with the insurer, have | | | 19|agreed to provide health care services to enrollees with an | | | 20|expectation of receiving payment, other than copayments, | | | 21|coinsurance, or deductibles, directly or indirectly, from the | | | 22|insurer; | | | 23| 11. "Prior authorization" means a written or oral | | | 24|determination made by a utilization review organization that a | | | Req. No. 14146 Page 4 ___________________________________________________________________________
1|health care service is a benefit covered under the applicable health | | | 2|benefit plan which, under the enrollee's clinical circumstances, is | | | 3|medically necessary or satisfies another requirement imposed by the | | | 4|insurer or utilization review organization, and thus satisfies the | | | 5|requirements for payment or reimbursement; | | | 6| 12. "Urgent care request" means a request for prior | | | 7|authorization of a health care service for which the time period for | | | 8|making a nonurgent determination of prior authorization could result | | | 9|in at least one of the following outcomes for the enrollee: | | | 10| a. death, | | | 11| b. permanent impairment of health, | | | 12| c. inability to regain maximum bodily function, or | | | 13| d. severe pain that cannot be adequately managed; and | | | 14| 13. "Utilization review organization" means the entity that | | | 15|makes determinations of prior authorization, which may be the | | | 16|insurer or other entity that is a designated contractor or agent of | | | 17|the insurer. | | | 18| SECTION 2. NEW LAW A new section of law to be codified | | | 19|in the Oklahoma Statutes as Section 6567.2 of Title 36, unless there | | | 20|is created a duplication in numbering, reads as follows: | | | 21| A. A prior authorization request that has not been submitted as | | | 22|an urgent care request is deemed approved if, within seventy-two | | | 23|(72) hours plus, if applicable, one (1) additional business day, | | | 24| | | | Req. No. 14146 Page 5 ___________________________________________________________________________
1|after the date and time of submission of the request, the | | | 2|utilization review organization fails to do one of the following: | | | 3| 1. Approve, deny, or fail in any way to acknowledge the | | | 4|request; | | | 5| 2. Request from the network provider all additional | | | 6|information needed to make a determination; or | | | 7| 3. Except for a prior authorization request for a prescription | | | 8|drug, fails to notify the network provider that a determination of | | | 9|prior authorization is delayed because the question of medical | | | 10|necessity is difficult to resolve. | | | 11| B. 1. If a network provider is requested to provide additional | | | 12|information, whether in the form of additional documentation or in | | | 13|the circumstances described in paragraph 2 of this subsection, the | | | 14|utilization review organization shall have an additional seventy-two | | | 15|(72) hours plus, if applicable, one (1) additional business day, | | | 16|after the date and time of submission of the additional information | | | 17|in which to make its decision or the prior authorization request is | | | 18|deemed approved; and | | | 19| 2. A request for additional information under paragraph 1 of | | | 20|this subsection shall include, in the case of a question of medical | | | 21|necessity which is difficult to resolve, all of the following: | | | 22| a. a direct phone number to the utilization review | | | 23| organization, | | | 24| | | | Req. No. 14146 Page 6 ___________________________________________________________________________
1| b. hours of availability of the utilization review | | | 2| organization's physician or other health care | | | 3| professional who has authority to make the prior | | | 4| authorization determination, and | | | 5| c. a statement that there is an opportunity to discuss | | | 6| the medical necessity of the health care service | | | 7| directly with the physician or other health care | | | 8| professional who has authority to make the prior | | | 9| authorization determination. | | | 10| C. Failure by the network provider to submit all clinical | | | 11|information, including its response to a request for additional | | | 12|information, within six (6) calendar days after the date of the | | | 13|initial submission of the request shall necessitate the network | | | 14|provider to request a new prior authorization. | | | 15| D. A network provider shall submit a request for a prior | | | 16|authorization that is not an urgent care request at least six (6) | | | 17|calendar days before the scheduled health care service. | | | 18| SECTION 3. NEW LAW A new section of law to be codified | | | 19|in the Oklahoma Statutes as Section 6567.3 of Title 36, unless there | | | 20|is created a duplication in numbering, reads as follows: | | | 21| A. A prior authorization request that is submitted as an urgent | | | 22|care request is deemed approved if, within twenty-four (24) hours | | | 23|after the date and time of submission of the request, the | | | 24|utilization review organization fails to do one of the following: | | | Req. No. 14146 Page 7 ___________________________________________________________________________
1| 1. Approve or deny the request; or | | | 2| 2. Request from the network provider all additional information | | | 3|needed to make a determination. | | | 4| B. 1. A network provider shall submit additional information | | | 5|requested by the utilization review organization within twenty-four | | | 6|(24) hours of receiving a request for additional information; and | | | 7| 2. The prior authorization request is deemed approved by the | | | 8|utilization review organization if it fails to grant or deny the | | | 9|request or otherwise respond to the submission of additional | | | 10|information by the network provider within twenty-four (24) hours | | | 11|after the date and time of submission of the requested additional | | | 12|information. | | | 13| C. Failure by the network provider to submit all clinical | | | 14|information in response to a request for additional information by | | | 15|the utilization review organization within twenty-four (24) hours | | | 16|after the date and time of the request shall necessitate the network | | | 17|provider to request a new prior authorization. | | | 18| SECTION 4. NEW LAW A new section of law to be codified | | | 19|in the Oklahoma Statutes as Section 6567.4 of Title 36, unless there | | | 20|is created a duplication in numbering, reads as follows: | | | 21| A utilization review organization shall ensure that all | | | 22|determinations on requests for prior authorization are made by a | | | 23|physician or other health care professional who is competent to | | | 24|evaluate and reject, if appropriate, any recommendation or | | | Req. No. 14146 Page 8 ___________________________________________________________________________
1|conclusion of artificial intelligence, based upon all relevant | | | 2|factors that include, but are not limited to, the enrollee's | | | 3|clinical circumstances, the information submitted by the network | | | 4|provider, and all applicable criteria, policies, and guidelines. | | | 5| SECTION 5. NEW LAW A new section of law to be codified | | | 6|in the Oklahoma Statutes as Section 6567.5 of Title 36, unless there | | | 7|is created a duplication in numbering, reads as follows: | | | 8| A. When a utilization review organization issues an adverse | | | 9|determination in response to a request for prior authorization, it | | | 10|shall send a notification of its determination to both the network | | | 11|provider and enrollee, which shall include all of the following | | | 12|information: | | | 13| 1. The reasons for the adverse determination and, if | | | 14|applicable, relevant evidence-based criteria, including a | | | 15|description of missing or insufficient documentation, or lack of | | | 16|coverage under the health benefit plan; | | | 17| 2. Instructions on how to appeal the determination; and | | | 18| 3. Additional documentation or other information necessary to | | | 19|support the appeal. | | | 20| B. In addition to the requirement of Section 4 of this act, a | | | 21|utilization review organization shall ensure that all adverse | | | 22|determinations are made by a physician who meets all of the | | | 23|following requirements: | | | 24| | | | Req. No. 14146 Page 9 ___________________________________________________________________________
1| 1. Possesses a current, nonrestricted license to practice | | | 2|medicine issued by an occupational licensure board in any state or | | | 3|territory of the United States; | | | 4| 2. Is board-eligible for certification or has equivalent | | | 5|clinical practice experience in the same specialty as the physician | | | 6|or other health care professional who would typically provide the | | | 7|health care service for which prior authorization is requested; | | | 8| 3. Makes determinations under the supervision of a medical | | | 9|director who is a current, licensed physician in the State of | | | 10|Oklahoma; and | | | 11| 4. Receives compensation or payment from the utilization | | | 12|review organization which is in no way increased or enhanced by | | | 13|making an adverse determination. | | | 14| SECTION 6. NEW LAW A new section of law to be codified | | | 15|in the Oklahoma Statutes as Section 6567.6 of Title 36, unless there | | | 16|is created a duplication in numbering, reads as follows: | | | 17| A. A utilization review organization shall make its process for | | | 18|appealing an adverse determination on a request for prior | | | 19|authorization readily accessible on its website to its network | | | 20|providers and enrollees. | | | 21| B. When an appeal is received from a network provider or | | | 22|enrollee on an adverse determination on a request for prior | | | 23|authorization, a utilization review organization shall send a | | | 24| | | | Req. No. 14146 Page 10 ___________________________________________________________________________
1|notification to both the network provider and enrollee confirming, | | | 2|reversing, or modifying the adverse determination within: | | | 3| 1. Seventy-two (72) hours plus, if applicable, one (1) | | | 4|additional business day, for a nonurgent request; or | | | 5| 2. Twenty-four (24) hours for an urgent request. | | | 6| C. A utilization review organization shall ensure that all | | | 7|appeals from adverse determinations are decided by a physician other | | | 8|than the physician who made the adverse determination and who meets | | | 9|the requirements of paragraphs 1 through 4 of subsection B of | | | 10|Section 5 of this act. | | | 11| SECTION 7. NEW LAW A new section of law to be codified | | | 12|in the Oklahoma Statutes as Section 6567.7 of Title 36, unless there | | | 13|is created a duplication in numbering, reads as follows: | | | 14| A. Beginning January 1, 2027, an insurer shall exempt a health | | | 15|care professional who is a network provider from obtaining prior | | | 16|authorization for a health care service covered under a health | | | 17|benefit plan when all of the following requirements are met: | | | 18| 1. The health care service is otherwise subject to a prior | | | 19|authorization requirement as a precondition to approval for payment | | | 20|or reimbursement; | | | 21| 2. The health care professional provided the health care | | | 22|service to at least seven different patients during the year 2025; | | | 23|and | | | 24| | | | Req. No. 14146 Page 11 ___________________________________________________________________________
1| 3. Prior authorization was approved, based upon the medical | | | 2|necessity criteria used by the utilization review organization, for | | | 3|ninety percent (90%) or more of the requests made by the health care | | | 4|professional for the health care service. | | | 5| B. The exemption provided in this section shall be effective | | | 6|for the succeeding year upon determination by the utilization review | | | 7|organization. | | | 8| C. 1. Notwithstanding subsection B of this section, an insurer | | | 9|may rescind the exemption at any time if the health care | | | 10|professional knowingly and materially misrepresents the health care | | | 11|service, including a substantial failure to provide the health care | | | 12|service, in a claim made with the specific intent to deceive the | | | 13|insurer and obtain an unlawful payment or reimbursement; | | | 14| 2. Notwithstanding subsection B of this section, an insurer may | | | 15|rescind the exemption no less than ninety (90) days after the | | | 16|exemption takes effect if the insurer or utilization review | | | 17|organization detects an increase in claims for payment or | | | 18|reimbursement for the health care service for which the exemption is | | | 19|granted that is disproportionate or anomalous to the health care | | | 20|professional's historic rate of providing the health care service; | | | 21|and | | | 22| 3. An insurer shall give written notice to a health care | | | 23|professional that the exemption is being rescinded no less than | | | 24|twenty (20) days in advance of the effective date of the rescission. | | | Req. No. 14146 Page 12 ___________________________________________________________________________
1| D. 1. An insurer may automatically renew an exemption from | | | 2|prior authorization for a health care service for a succeeding year | | | 3|if the health care professional submits fewer than seven (7) claims | | | 4|for payment or reimbursement for the health care service during the | | | 5|current exemption year, or for any other reason in the insurer's | | | 6|discretion; | | | 7| 2. a. an insurer may retrospectively review the health care | | | 8| professional's provision of the health care service | | | 9| during the exemption year, using a review period of at | | | 10| least nine (9) months, as a condition for renewing the | | | 11| exemption for the succeeding year, | | | 12| b. pursuant to a retrospective review, an insurer may | | | 13| decline to renew the exemption on any of the following | | | 14| grounds: | | | 15| (1) the review discloses that less than ninety | | | 16| percent (90%) of the claims paid or reimbursed | | | 17| would meet the medical necessity criteria used by | | | 18| the utilization review organization, or | | | 19| (2) the review discloses a claim or a pattern that | | | 20| would be grounds for rescission of the exemption | | | 21| as described in subsection c of this section; and | | | 22| 3. An insurer shall make efforts to ensure that written notice | | | 23|of a decision granting or declining renewal of an exemption is | | | 24|provided to a health care professional who has a current exemption | | | Req. No. 14146 Page 13 ___________________________________________________________________________
1|no later than at least thirty (30) days before the one-year | | | 2|exemption period expires. | | | 3| E. 1. When an insurer rescinds or declines to renew an | | | 4|exemption from prior authorization for a health care service, it | | | 5|shall send written notice of its decision to the health care | | | 6|professional, which shall include: | | | 7| a. the reason for the decision, and | | | 8| b. instructions on how to submit a request for | | | 9| reconsideration of the decision; | | | 10| 2. A health care professional may submit a request for | | | 11|reconsideration of a decision to rescind or decline renewal of an | | | 12|exemption within twenty (20) days of receiving notice of the health | | | 13|insurer's decision; | | | 14| 3. a. an insurer shall afford a health care professional a | | | 15| reasonable opportunity, including by a meeting or | | | 16| informal hearing conducted in person or | | | 17| electronically, to challenge the grounds for a | | | 18| decision to rescind or decline renewal of an | | | 19| exemption, to include the presentation of any relevant | | | 20| documentation such as clinical records or claims data | | | 21| as may be relevant to the reason for the insurer's | | | 22| decision, and | | | 23| b. reconsideration of a decision to decline renewal | | | 24| which involves the issue of medical necessity shall be | | | Req. No. 14146 Page 14 ___________________________________________________________________________
1| performed on behalf of the insurer by a physician who | | | 2| meets the requirements of subsection B of Section 5 of | | | 3| this act; | | | 4| 4. A decision by a health insurer on reconsideration, affirming | | | 5|or denying its rescission or nonrenewal, is final; | | | 6| 5. All information, including, but not limited to, oral or | | | 7|written communications, clinical records, supporting documentation, | | | 8|up to the reason for rescinding or declining to renew an exemption, | | | 9|or any decision on a request for reconsideration, shall be held in | | | 10|the strictest confidence by both the insurer and the health care | | | 11|professional, subject to any of the following: | | | 12| a. reporting by an insurer of the facts of a case | | | 13| described in paragraph 1 of subsection C of this | | | 14| section to the commissioner, an occupational licensing | | | 15| board, or law enforcement, | | | 16| b. disclosure to a third party by mutual, written | | | 17| agreement of the insurer and the health care | | | 18| professional, subject to the federal Health Insurance | | | 19| Portability and Accountability Act (HIPAA), 42 U.S.C. | | | 20| Section 1320d et seq., or | | | 21| c. use by the insurer or health care provider as | | | 22| necessary to invoke or enforce any provision under a | | | 23| network provider contract. | | | 24| F. A health care professional who has been granted an | | | Req. No. 14146 Page 15 ___________________________________________________________________________
1|exemption from prior authorization for a health care service | | | 2|which has been rescinded or not renewed, and who is otherwise | | | 3|a network provider, remains automatically eligible to receive | | | 4|an exemption for a subsequent year for any health care service | | | 5|he or she provides which may qualify for exemption, unless an | | | 6|exemption was rescinded in a case described in paragraph 1 of | | | 7|subsection C of this section. | | | 8| G. An exemption from prior authorization under this section | | | 9|shall not apply to any health care service that is deemed by the | | | 10|health care insurer to be experimental. | | | 11| SECTION 8. NEW LAW A new section of law to be codified | | | 12|in the Oklahoma Statutes as Section 6567.8 of Title 36, unless there | | | 13|is created a duplication in numbering, reads as follows: | | | 14| The Oklahoma Insurance Commissioner may adopt any rules | | | 15|necessary to implement and enforce this act. | | | 16| SECTION 9. This act shall become effective November 1, 2026. | | | 17| | | | 18| 60-2-14146 MJ 01/06/26 | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | Req. No. 14146 Page 16