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An Act
ENROLLED HOUSE
BILL NO. 1810 By: Newton of the House
and
Gillespie of the Senate
An Act relating to the state Medicaid program;
amending 56 O.S. 2021, Section 4002.2, as last
amended by Section 1, Chapter 448, O.S.L. 2024 (56
O.S. Supp. 2024, Section 4002.2), which relates to
definitions used in the Ensuring Access to Medicaid
Act; modifying and adding definitions; amending 56
O.S. 2021, Section 4002.6, as last amended by Section
5, Chapter 448, O.S.L. 2024 (56 O.S. Supp. 2024,
Section 4002.6), which relates to prior
authorizations; modifying and removing certain
requirements of contracted entities; clarifying
applicability of certain provisions; providing
certain notice and publication requirements;
specifying qualifications for review of adverse
determinations; requiring implementation of certain
application programming interface; stipulating
certain time periods for prior authorization
determinations; deeming requested services authorized
under certain conditions; defining term; prohibiting
prior authorization and stipulating certain
procedures for emergency services; requiring and
prohibiting certain acts related to duration of prior
authorizations; requiring certain opportunity for
communication; directing certain reimbursement except
under specified conditions; amending 56 O.S. 2021,
Section 4002.8, as amended by Section 12, Chapter
395, O.S.L. 2022 (56 O.S. Supp. 2024, Section
4002.8), which relates to appeals of adverse
determinations; modifying qualifications for review
of appeals; updating statutory language; repealing 56
O.S. 2021, Section 4002.2, as last amended by Section
1, Chapter 206, O.S.L. 2024 (56 O.S. Supp. 2024,
Section 4002.2), which relates to definitions;
ENR. H. B. NO. 1810 Page 2
providing an effective date; and declaring an
emergency.
SUBJECT: State Medicaid program
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 56 O.S. 2021, Section 4002.2, as
last amended by Section 1, Chapter 448, O.S.L. 2024 (56 O.S. Supp.
2024, Section 4002.2), is amended to read as follows:
Section 4002.2. As used in the Ensuring Access to Medicaid Act:
1. “Adverse determination” has the same meaning as provided by
Section 6475.3 of Title 36 of the Oklahoma Statutes means a
determination by a contracted entity or its designee utilization
review entity that an admission, availability of care, continued
stay, or other health care service that is a covered Medicaid
benefit has been reviewed and, based upon the information provided,
does not meet the contracted entity’s or the Oklahoma Health Care
Authority’s requirements for medical necessity, appropriateness,
health care setting, level of care, or effectiveness, and the
requested service or payment for the service is therefore denied,
reduced, or terminated;
2. “Accountable care organization” means a network of
physicians, hospitals, and other health care providers that provides
coordinated care to Medicaid members;
3. “Claims denial error rate” means the rate of claims denials
that are overturned on appeal;
4. “Capitated contract” means a contract between the Oklahoma
Health Care Authority and a contracted entity for delivery of
services to Medicaid members in which the Authority pays a fixed,
per-member-per-month rate based on actuarial calculations;
5. “Children’s Specialty Plan” means a health care plan that
covers all Medicaid services other than dental services and is
designed to provide care to:
a. children in foster care,
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b. former foster care children up to twenty-five (25)
years of age,
c. juvenile-justice-involved children, and
d. children receiving adoption assistance, and
e. on and after July 1, 2026:
(1) children involved in a Family Centered Services
(FCS) case through the Child Welfare Services
division of the Department of Human Services,
(2) children in the custody of the Department of
Human Services and placed at home under court
supervision,
(3) children who are placed at home in a trial
reunification plan administered by the Department
of Human Services, and
(4) Medicaid enrolled parents and guardians whose
children are in an FCS case, are in trial
reunification, or are in the custody of the
Department of Human Services in foster care or
under court supervision;
6. “Clean claim” means a properly completed billing form with
Current Procedural Terminology, 4th Edition or a more recent
edition, the Tenth Revision of the International Classification of
Diseases coding or a more recent revision, or Healthcare Common
Procedure Coding System coding where applicable that contains
information specifically required in the Provider Billing and
Procedure Procedures Manual of the Oklahoma Health Care Authority,
as defined in 42 C.F.R., Section 447.45(b);
7. “Clinical criteria” means the written policies, written
screening procedures, determination rules, determination abstracts,
clinical protocols, practice guidelines, medical protocols, and any
other criteria or rationale used by a contracted entity to determine
the necessity and appropriateness of health care services;
8. “Commercial plan” means an organization or entity that
undertakes to provide or arrange for the delivery of health care
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services to Medicaid members on a prepaid basis and is subject to
all applicable federal and state laws and regulations;
8. 9. “Contracted entity” means an organization or entity that
enters into or will enter into a capitated contract with the
Oklahoma Health Care Authority for the delivery of services
specified in the Ensuring Access to Medicaid Act that will assume
financial risk, operational accountability, and statewide or
regional functionality as defined in the Ensuring Access to Medicaid
Act in managing comprehensive health outcomes of Medicaid members.
For purposes of the Ensuring Access to Medicaid Act, the term
contracted entity includes an accountable care organization, a
provider-led entity, a commercial plan, a dental benefit manager, or
any other entity as determined by the Authority;
9. 10. “Dental benefit manager” means an entity that handles
claims payment and prior authorizations and coordinates dental care
with participating providers and Medicaid members;
10. 11. “Essential community provider” means:
a. a Federally Qualified Health Center,
b. a community mental health center,
c. an Indian Health Care Provider,
d. a rural health clinic,
e. a state-operated mental health hospital,
f. a long-term care hospital serving children (LTCH-C),
g. a teaching hospital owned, jointly owned, or
affiliated with and designated by the University
Hospitals Authority, University Hospitals Trust,
Oklahoma State University Medical Authority, or
Oklahoma State University Medical Trust,
h. a provider employed by or contracted with, or
otherwise a member of the faculty practice plan of:
(1) a public, accredited medical school in this
state, or
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(2) a hospital or health care entity directly or
indirectly owned or operated by the University
Hospitals Trust or the Oklahoma State University
Medical Trust,
i. a county department of health or city-county health
department,
j. a comprehensive community addiction recovery center,
k. a hospital licensed by this state including all
hospitals participating in the Supplemental Hospital
Offset Payment Program,
l. a Certified Community Behavioral Health Clinic
(CCBHC),
m. a provider employed by or contracted with a primary
care residency program accredited by the Accreditation
Council for Graduate Medical Education,
n. any additional Medicaid provider as approved by the
Authority if the provider either offers services that
are not available from any other provider within a
reasonable access standard or provides a substantial
share of the total units of a particular service
utilized by Medicaid members within the region during
the last three (3) years, and the combined capacity of
other service providers in the region is insufficient
to meet the total needs of the Medicaid members,
o. a pharmacy or pharmacist, or
p. any provider not otherwise mentioned in this paragraph
that meets the definition of “essential community
provider” under 45 C.F.R., Section 156.235;
11. “Material change” includes, but is not limited to, any
change in overall business operations such as policy, process or
protocol which affects, or can reasonably be expected to affect,
more than five percent (5%) of enrollees or participating providers
of the contracted entity;
12. “Governing body” means a group of individuals appointed by
the contracted entity who approve policies, operations, profit/loss
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ratios, executive employment decisions, and who have overall
responsibility for the operations of the contracted entity of which
they are appointed;
13. “Health care service” means any service provided by a
participating provider, or by an individual working for or under the
supervision of the participating provider, that relates to the
diagnosis, assessment, prevention, treatment, or care of any human
illness, disease, injury, or condition. Unless the context clearly
indicates otherwise, health care service includes the provision of
mental health and substance use disorder services and the provision
of durable medical equipment;
14. “Local Oklahoma provider organization” means any state
provider association, accountable care organization, Certified
Community Behavioral Health Clinic, Federally Qualified Health
Center, Native American tribe or tribal association, hospital or
health system, academic medical institution, currently practicing
licensed provider, or other local Oklahoma provider organization as
approved by the Authority;
14. “Medical necessity” has the same meaning as “medically
15. “Material change” includes, but is not limited to, any
change in overall business operations such as policy, process, or
protocol which affects, or can reasonably be expected to affect,
more than five percent (5%) of members or participating providers of
the contracted entity;
16. “Medically necessary” in Section 6592 of Title 36 of the
Oklahoma Statutes means services or supplies provided by a
participating provider that are:
a. appropriate for the symptoms and diagnosis or
treatment of a member’s condition, illness, disease,
or injury,
b. in accordance with standards of good medical practice,
c. not primarily for the convenience of the member or the
member’s health care provider, and
d. the most appropriate supply or level of service that
can safely be provided to the member as determined by
the Authority;
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15. 17. “Participating provider” means a provider who has a
contract with or is employed by a contracted entity to provide
services to Medicaid members as authorized by the Ensuring Access to
Medicaid Act;
18. “Prior authorization” means the process by which a
contracted entity or its designee utilization review entity
determines the medical necessity and medical appropriateness of
otherwise covered health care services prior to the rendering of
such health care services;
16. 19. “Provider” means a health care or dental provider
licensed or certified in this state or a provider that meets the
Authority’s provider enrollment criteria to contract with the
Authority as a SoonerCare provider;
17. 20. “Provider-led entity” means an organization or entity,
a majority of whose governing body is composed of individuals who:
a. have experience serving Medicaid members and:
(1) are licensed in this state as physicians,
physician assistants, or Advanced Practice
Registered Nurses,
(2) at least one board member is a licensed
behavioral health provider, or
(3) are employed by:
(a) a hospital or other medical facility
licensed by this state and operating in this
state, or
(b) an inpatient or outpatient mental health or
substance abuse treatment facility or
program licensed or certified by this state
and operating in this state,
b. represent the providers or facilities described in
subparagraph a of this paragraph including, but not
limited to, individuals who are employed by a
statewide provider association, or
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c. are nonclinical administrators of clinical practices
serving Medicaid members;
18. 21. “Provider-owned entity” means an organization or
entity, a majority of whose ownership is held by Medicaid providers
in this state or is held by an entity that directly or indirectly
owns or is under common ownership with Medicaid providers in this
state;
19. 22. “Statewide” means all counties of this state including
the urban region; and
20. 23. “Urban region” means:
a. all counties of this state with a county population of
not less than five hundred thousand (500,000)
according to the latest Federal Decennial Census, and
b. all counties that are contiguous to the counties
described in subparagraph a of this paragraph,
combined into one region; and
24. “Urgent health care service” means, with respect to the
application of the time period for making a prior authorization
determination under Section 4002.6 of this title, a health care
service which, in the opinion of a physician with knowledge of the
member’s medical condition:
a. could seriously jeopardize the life or health of the
member or the ability of the member to regain maximum
function, or
b. in the opinion of a physician with knowledge of the
member’s medical condition, would subject the member
to severe pain that cannot be adequately managed
without the care or treatment that is the subject of
the prior authorization.
SECTION 2. AMENDATORY 56 O.S. 2021, Section 4002.6, as
last amended by Section 5, Chapter 448, O.S.L. 2024 (56 O.S. Supp.
2024, Section 4002.6), is amended to read as follows:
Section 4002.6. A. A contracted entity shall meet all
requirements established by the Oklahoma Health Care Authority this
section pertaining to prior authorizations. The Authority shall
ENR. H. B. NO. 1810 Page 9
establish requirements that ensure timely determinations by
contracted entities when prior authorizations are required including
expedited review in urgent and emergent cases that at a minimum meet
the criteria of this section.
B. A contracted entity shall make a determination on a request
for an authorization of the transfer of a hospital inpatient to a
post-acute care or long-term acute care facility within twenty-four
(24) hours of receipt of the request.
C. A contracted entity shall make a determination on a request
for any member who is not hospitalized at the time of the request
within seventy-two (72) hours of receipt of the request; provided,
that if the request does not include sufficient or adequate
documentation, the review and determination shall occur within a
time frame and in accordance with a process established by the
Authority. The process established by the Authority pursuant to
this subsection shall include a time frame of at least forty-eight
(48) hours within which a provider may submit the necessary
documentation.
D. A contracted entity shall make a determination on a request
for services for a hospitalized member including, but not limited
to, acute care inpatient services or equipment necessary to
discharge the member from an inpatient facility within twenty-four
(24) hours of receipt of the request.
E. Notwithstanding the provisions of subsection C of this
section, a contracted entity shall make a determination on a request
as expeditiously as necessary and, in any event, within twenty-four
(24) hours of receipt of the request for service if adhering to the
provisions of subsection C or D of this section could jeopardize the
member’s life, health or ability to attain, maintain or regain
maximum function. In the event of a medically emergent matter, the
contracted entity shall not impose limitations on providers in
coordination of post-emergent stabilization health care including
pre-certification or prior authorization.
F. Notwithstanding any other provision of this section, a
contracted entity shall make a determination on a request for
inpatient behavioral health services within twenty-four (24) hours
of receipt of the request.
G. A To the extent a contracted entity uses a third-party
utilization review entity to administer prior authorizations on its
ENR. H. B. NO. 1810 Page 10
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.
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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 on a request 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 that are required to be
prior authorized by the Authority, within twenty-four
(24) hours of receipt of the request 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.
H. A contracted entity shall make a determination on a request,
and
d. for coverage of biomarker testing, in accordance with
Section 4003 of this title.
I. Upon issuance of an adverse determination on a prior
authorization request under subsection B of this section, the
contracted entity shall provide the requesting provider, within
seventy-two (72) hours of receipt of such issuance, with reasonable
opportunity to participate in a peer-to-peer review process with a
provider who practices in the same specialty, but not necessarily
the same sub-specialty, and who has experience treating the same
ENR. H. B. NO. 1810 Page 12
population as the patient on whose behalf the request is submitted;
provided, however, if the requesting provider determines the
services to be clinically urgent, the contracted entity shall
provide such opportunity within twenty-four (24) hours of receipt of
such issuance. Services not covered under the state Medicaid
program for the particular patient shall not be subject to peer-to-
peer review.
J. The Authority shall ensure that a provider offers to provide
to a member in a timely manner services authorized by a contracted
entity.
K. The Authority shall establish requirements for both internal
and external reviews and appeals of adverse determinations on prior
authorization requests or claims that, at a minimum:
1. Require contracted entities to provide a detailed
explanation of denials to Medicaid providers and members;
2. Require contracted entities to provide an opportunity for
peer-to-peer conversations with Oklahoma-licensed clinical staff of
the same or similar specialty within twenty-four (24) hours of the
adverse determination; and
3. Establish uniform rules for Medicaid provider or member
appeals across all contracted entities.
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
ENR. H. B. NO. 1810 Page 13
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
ENR. H. B. NO. 1810 Page 14
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.
SECTION 3. AMENDATORY 56 O.S. 2021, Section 4002.8, as
amended by Section 12, Chapter 395, O.S.L. 2022 (56 O.S. Supp. 2024,
Section 4002.8), is amended to read as follows:
Section 4002.8. A. A contracted entity shall utilize uniform
procedures established by the Authority under subsection B of this
section for the review and appeal of any adverse determination by
the contracted entity sought by any enrollee member or provider
adversely affected by such determination.
B. The Authority shall develop procedures for enrollees members
or providers to seek review by the contracted entity of any adverse
determination made by the contracted entity.
C. A provider shall have six (6) months from the receipt of a
claim denial to file an appeal. With respect to
D. A contracted entity shall ensure that all appeals of adverse
determinations made by a the contracted entity on the basis of
medical necessity, the following requirements shall apply:
1. Medical review staff of the contracted entity shall be
licensed or credentialed health care clinicians with relevant
clinical training or experience; and
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2. All contracted entities shall use medical review staff for
such appeals and are reviewed by a licensed physician or, if
appropriate for the requested service, a licensed mental health
professional. The contracted entity shall not use any automated
claim review software or other automated functionality for such
appeals.
E. The physician or mental health professional who reviews the
appeal shall:
1. Possess a current and valid unrestricted license in any
United States jurisdiction;
2. Be of the same or similar specialty as a physician or mental
health professional who typically manages the medical condition or
disease. This requirement shall be considered met:
a. for a physician, if:
(1) the physician maintains board certification for
the same or similar specialty as the medical
condition in question, or
(2) the physician’s training and experience:
(a) includes treatment of the condition,
(b) includes treatment of complications that may
result from the service or procedure, and
(c) is sufficient for the physician to determine
if the service or procedure is medically
necessary or clinically appropriate, or
b. for a mental health professional, if the mental health
professional’s training and experience:
(1) includes treatment of the condition, and
(2) is sufficient for the mental health professional
to determine if the service is medically
necessary or clinically appropriate;
3. Not have been directly involved in making the adverse
determination;
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4. Not have any financial interest in the outcome of the
appeal; and
5. Consider all known clinical aspects of the health care
service under review including, but not limited to, a review of any
medical records pertinent to the active condition that are provided
to the contracted entity by the member’s provider, or a health care
facility, and any pertinent medical literature provided to the
contracted entity by the provider.
C. F. Upon receipt of notice from the contracted entity that
the adverse determination has been upheld on appeal, the enrollee
member or provider may request a fair hearing from the Authority.
The Authority shall develop procedures for fair hearings in
accordance with 42 C.F.R., Part 431.
SECTION 4. REPEALER 56 O.S. 2021, Section 4002.2, as
last amended by Section 1, Chapter 206, O.S.L. 2024 (56 O.S. Supp.
2024, Section 4002.2), is hereby repealed.
SECTION 5. Sections 1, 2, and 3 of this act shall become
effective November 1, 2025.
SECTION 6. It being immediately necessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whereof this act shall take effect and
be in full force from and after its passage and approval.
ENR. H. B. NO. 1810 Page 17
Passed the House of Representatives the 15th day of May, 2025.
Presiding Officer of the House
of Representatives
Passed the Senate the 7th day of May, 2025.
Presiding Officer of the Senate
OFFICE OF THE GOVERNOR
Received by the Office of the Governor this ____________________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________
Approved by the Governor of the State of Oklahoma this _________
day of ___________________, 20_______, at _______ o'clock _______ M.
_________________________________
Governor of the State of Oklahoma
OFFICE OF THE SECRETARY OF STATE
Received by the Office of the Secretary of State this __________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________