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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.


**UPDATED**    Independent Review Organizations (External Review)
Recent changes in Oklahoma law transferred responsibility for external reviews to the Oklahoma Insurance Department (OID).  The Uniform Health Carrier External Review Act, House Bill 2072, sections 25-41, was effective August 26, 2011.  Petitioners and health benefit plans have been notified by letter regarding the transition.  Click here to review House Bill 2072.

Pending external review cases that were accepted for full review by the selected Independent Review Organization remain valid.   After August 26, 2011, all future correspondence regarding an external review should be directed to the Oklahoma Insurance Department’s Consumer Assistance.  The contact information for Consumer Assistance is listed below.

Consumer Assistance 
Five Corp Corporate Plaza 
3625 NW 56th, Suite 100           
Oklahoma City, OK 73112-4511
Telephone Number: 405.521.2828
Toll Free: 800.522.0071
Fax: 405.521.6635
Web: http://www.ok.gov/oid/Consumers/Consumer_Assistance/index.html

A consumer assistance representative will be assigned to work your request for external review. If you have other questions about this process you may contact John W. Judge, Jr. at (405) 271.9444, ext. 57273.


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., Director
Managed Care Systems
Health Resources Development Service
1000 N.E. 10th Street, Room 1011
Oklahoma City, OK 73117
Phone  405.271.6868
Fax  405.271.7360
E-mail
   Click Here

 

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