§ 36-6552. Definitions.

As used in the Hospital and Medical Services Utilization Review Act:

1.  "Utilization review" means a system for prospectively, concurrently and retrospectively reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients.  It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;

2.  "Private review agent" means a person or entity who performs utilization review on behalf of:

a.an employer in this state, or

b.a third party that provides or administers hospital and medical benefits to citizens of this state, including, but not limited to:

(1)a health maintenance organization issued a license pursuant to Section 2501 et seq. of Title 63 of the Oklahoma Statutes, unless the health maintenance organization is federally regulated and licensed and has on file with the Commissioner of Health a plan of utilization review carried out by health care professionals and providing for complaint and appellate procedures for claims, or

(2)a health insurer, not-for-profit hospital service or medical plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state;

3.  "Utilization review plan" means a description of utilization review procedures;

4.  "Commissioner" means the Insurance Commissioner;

5.  "Certificate" means a certificate of registration granted by the Insurance Commissioner to a private review agent; and

6.  "Health care provider" means any person, firm, corporation or other legal entity that is licensed, certified, or otherwise authorized by the laws of this state to provide health care services, procedures or supplies in the ordinary course of business or practice of a profession.

Added by Laws 1991, c. 294, § 2, eff. Nov. 1, 1991.