§ 36-6592. Definitions.

For purposes of this act:

1.  "Enrollee" means an individual who is enrolled in a health care plan, including covered dependents;

2.  "Health care plan" means any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the costs of any health care services for an enrollee;

3.  "Health care provider" means a physician, hospital, pharmaceutical company, pharmacy, pharmacist, laboratory, or other state-licensed or state-recognized provider of health care services;

4.  "Health insurance carrier" means an insurance company that issues policies of accident and health insurance and is or should be licensed to sell insurance in this state;

5.  "Health maintenance organization" means an organization which is or should be licensed by the State Department of Health pursuant to Section 2501 et seq. of Title 63 of the Oklahoma Statutes;

6.  "Managed care entity" means any entity which is a health care plan, health insurance carrier or health maintenance organization as defined in this section, but does not include an employer that sponsors or participates in a health care plan or purchases coverage or assumes risk on behalf of or for the benefit of its employees or the employees of one or more subsidiaries or affiliates of the employer; and

7.  "Medically necessary” means services or supplies provided by a health care provider that are:

a.              appropriate for the symptoms and diagnosis or treatment of the enrollee’s condition, illness, disease, or injury,

b.              in accordance with standards of good medical practice,

c.              not primarily for the convenience of the enrollee or the enrollee’s health care provider, and

d.              the most appropriate supply or level of service that can safely be provided to the enrollee.

Added by Laws 2000, c. 163, § 2, eff. July 1, 2000.