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