Managed Care Systems

Health Maintenance Organization (HMO)
The Oklahoma State Department of Health certifies to the Oklahoma Insurance Commissioner that each HMO is in compliance with Section 6907 of the HMO Act of 2003. The Health Department’s certification review includes quality of health care, internal quality assurance, patient record keeping and clinical records, provider credentialing and emergency services. The Health Department’s Managed Care Division staff administers the quality review process.With the sharing of responsibility between two agencies, there will be enhanced consumer and provider protections. The Insurance Department will focus on financial and consumer-protection issues and the Health Department will focus on health and quality assurance.

Independent Review Organizations (External Review)
External review is an option available to the member who meets certain statutory requirements once the internal review process with the plan has been completed. External review involves a case review by an independent review organization certified by the Department.

Managed Care Referral
This law addresses referral to and treatment by specialists, allowing a specialist to coordinate both primary and specialty care, and standing referrals to a specialist. Managed care plans must continue coverage of services for certain specified conditions for up to 90 days after termination of participating providers. Requires a managed care plan to approve or disapprove a request for a nonformulary drug or a drug that requires prior authorization within 24 hours.

Workplace Medical Plan Certification
Certified workplace medical plans contract with insurers and employers to provide health and medical services for work-related injuries. The Commissioner of Health is the certifying authority for this type of managed care authorized under Oklahoma's Workers' Compensation Act.

Contact Information
John W. Judge, Jr.
Managed Care Systems
Health Resources Development Service
1000 N.E. 10th Street, Room 1011
Oklahoma City, OK 73117-1299
Phone  405.271.6868
Fax  405.271.7360
E-mail   johnwj@health.ok.gov  or
            healthresources@health.ok.gov