Utilization Review Licensing in Oklahoma

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Oklahoma. For assistance with licensing, please contact us to learn about our software and managed license services.

Oklahoma Independent Review Organization Registration

Agency:Oklahoma Insurance Department
Law:

36 OK Stat. 36-6475.12

Foreign Qualification is Prerequisite:Yes
Registered Agent (Special Agency) Required?No

Initial Registration

Form:

Application for Registration as an Independent Review Organization

Agency Fee:

$0

Required Attachments:
  • A copy of the most recent certificate from American Accreditation HealthCare Commission/URAC for Independent Review Organizations
  • A schedule of fees
  • A copy of the current Certificate of Authority provided by the Oklahoma Secretary of State

Registration Renewal

Form:

Application for Registration as an Independent Review Organization (Renewal)

Agency Fee:

$0

Due:

Biennially by December 31. The first renewal is due by December 31 of the calendar year following approval.

Supplemental Reporting
Independent Review Organization External Review Annual Report

Form:

Independent Review Organization External Review Annual Report

Agency Fee:

$0

Due:

Annually by January 31.

Law:

OAC 365:10-29-10

Oklahoma Utilization Review Registration

Type of Review:

Medical Utilization Review

Agency:Oklahoma Insurance Department
Law:

36 OK Stat § 36-6553

Initial Registration

Form:

Utilization Review Certification and/or Registration Application

Filing Method:

Applicants must use the online SERFF system to apply.

Agency Fee:

$500

Notarization Required?:Required
Required Attachments:
  • List of all other office locations
  • Copy of the utilization review plan
  • List of the type and qualifications of the personnel either employed or under contract to perform the utilization review
  • Procedures and policies in place to ensure that a representative of the private review agent is reasonably accessible
  • Policies and procedures in place to ensure that all applicable State and Federal laws to protect the confidentiality of individual medical records are followed
  • Policies and procedures in place to verify and identity the authority of personnel performing utilization review by telephone
  • A copy of all materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan
  • A list of the third party payers for which the private review agent is performing utilization review in this state. Said list may be deemed confidential by the Commissioner for the purpose of protecting competition between agents
  • Procedures in place for handling complaints by patients and health care providers concerning utilization review
  • Procedures in place to ensure that after a request for medical evaluation, treatment, or procedures has been rejected in whole or in part and in the event a copy of the report on said rejection is requested, a copy of the report of the private review agent concerning the rejection shall be mailed by the insurer, postage prepaid, to the ill or injured person, the treating healthcare provider, or to the person financially responsible for the patient’s bill within fifteen (15) days after the receipt of the request for the report

Registration Renewal

Form:

Utilization Review Certification and/or Registration Annual Renewal Application

Filing Method:

Applicants must use the online SERFF system to renew.

Agency Fee:

$500

Due:

Annually by the anniversary of initial registration.

Notarization Required?:Required

Oklahoma Resources

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Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised February 22, 2021. Complete data last reviewed February 22, 2021.
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