1| SENATE FLOOR VERSION | | February 16, 2026 | 2| AS AMENDED | | | 3|SENATE BILL NO. 1553 By: Kern | | | 4| | | | 5| | | | 6| [ Medicaid - adverse determinations - appeal - costs | | - effective date ] | 7| | | | 8| | | | 9|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 10| SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.8, as | | | 11|last amended by Section 3, Chapter 372, O.S.L. 2025 (56 O.S. Supp. | | | 12|2025, Section 4002.8), is amended to read as follows: | | | 13| Section 4002.8. A. A contracted entity shall utilize uniform | | | 14|procedures established by the Oklahoma Health Care Authority under | | | 15|subsection B of this section for the review and appeal of any | | | 16|adverse determination by the contracted entity sought by any member | | | 17|or provider adversely affected by such determination. | | | 18| B. The Authority shall develop procedures for members or | | | 19|providers to seek review by the contracted entity of any adverse | | | 20|determination made by the contracted entity. | | | 21| C. A provider shall have six (6) months from the receipt of a | | | 22|claim denial to file an appeal. | | | 23| D. A contracted entity shall ensure that all appeals of adverse | | | 24|determinations made by the contracted entity are reviewed by a | | | arsid8153365 SENATE FLOOR VERSION - SB1553 SFLR Page 1 ___________________________________________________________________________
1|licensed physician or, if appropriate for the requested service, a | | | 2|licensed psychologist or mental health professional. The contracted | | | 3|entity shall not use any automated claim review software or other | | | 4|automated functionality for such appeals. | | | 5| E. The physician, psychologist, or other mental health | | | 6|professional who reviews the appeal shall: | | | 7| 1. Possess a current and valid unrestricted license in any | | | 8|United States jurisdiction; | | | 9| 2. Be of the same or similar specialty as a physician, | | | 10|psychologist, or other mental health professional who typically | | | 11|manages the medical condition or disease. This requirement shall be | | | 12|considered met: | | | 13| a. for a physician, if: | | | 14| (1) the physician maintains board certification for | | | 15| the same or similar specialty as the medical | | | 16| condition in question, or | | | 17| (2) the physician's training and experience: | | | 18| (a) includes treatment of the condition, | | | 19| (b) includes treatment of complications that | | | 20| may result from the service or procedure, | | | 21| and | | | 22| (c) is sufficient for the physician to | | | 23| determine if the service or procedure is | | | 24| | | | arsid8153365 SENATE FLOOR VERSION - SB1553 SFLR Page 2 ___________________________________________________________________________
1| medically necessary or clinically | | | 2| appropriate,or| | | 3| b. for a psychologist, if: | | | 4| (1) the psychologist is currently licensed in | | | 5| accordance with the Psychologists Licensing Act, | | | 6| (2) the psychologist has training and experience in | | | 7| the testing for and treatment of the condition, | | | 8| and | | | 9| (3) the psychologist's training and experience is | | | 10| sufficient to determine if the service is | | | 11| medically necessary or clinically appropriate, or | | | 12| c. for a mental health professional other than a | | | 13| psychologist, if the mental health professional's | | | 14| training and experience: | | | 15| (1) includes treatment of the condition, and | | | 16| (2) is sufficient for the mental health professional | | | 17| to determine if the service is medically | | | 18| necessary or clinically appropriate; | | | 19| 3. Not have been directly involved in making the adverse | | | 20|determination; | | | 21| 4. Not have any financial interest in the outcome of the | | | 22|appeal; and | | | 23| 5. Consider all known clinical aspects of the health care | | | 24|service under review including, but not limited to, a review of any | | | arsid8153365 SENATE FLOOR VERSION - SB1553 SFLR Page 3 ___________________________________________________________________________
1|medical records pertinent to the active condition that are provided | | | 2|to the contracted entity by the member's provider, or a health care | | | 3|facility, and any pertinent medical literature provided to the | | | 4|contracted entity by the provider. | | | 5| F. 1. Upon receipt of notice from the contracted entity that | | | 6|the adverse determination has been upheld on appeal, the member or | | | 7|provider may request a fair hearing from the Authority. The | | | 8|Authority shall develop procedures for fair hearings in accordance | | | 9|with 42 C.F.R., Part 431. | | | 10| 2. Such procedures shall provide for the recovery of costs by a | | | 11|psychologist or other mental health provider from the contracted | | | 12|entity for time and expenses related to the appeal if the adverse | | | 13|determination of the contracted entity is reversed through the fair | | | 14|hearing. The procedures for calculation of such costs shall take | | | 15|into account the time spent by the psychologist or other mental | | | 16|health provider on the administration of the appeal that would have | | | 17|otherwise been spent providing services to patients. | | | 18| SECTION 2. This act shall become effective November 1, 2026. | | | 19|COMMITTEE REPORT BY: COMMITTEE ON HEALTH AND HUMAN SERVICES | |February 16, 2026 - DO PASS AS AMENDED | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | arsid8153365 SENATE FLOOR VERSION - SB1553 SFLR Page 4