SECTION 260:40-5-10. Claims Procedure

(a)   The EGID has written rules in Title 260 of the Oklahoma Administrative Code which define the EGID's benefits and grievance procedure;

(1)   Employees Health, Life, and Dental Plans;

(2)   The Disability Program; and

(3)   Hearings Procedures.

(b)   Participants covered by the plans of the EGID shall use the EGID's grievance procedure.

(c)   The EBD may contract with one or more health maintenance organizations, insurance companies, or other agencies to provide benefits to a participant. If a benefit plan provides for a specific grievance process, the procedure for that benefit plan shall be used.

(d)   The EBD shall make the final determination as to whether provider plans are being administered consistently with the provisions of the EBD's Basic Plan or as otherwise contracted. Upon its determination that any benefit provider is not satisfying the requirements of the Basic Plan or the terms of its contract, the EBD may order corrective action as needed.

(e)   The EBD shall only have authority to determine the rights of any participant or beneficiary in a Health Care Reimbursement Account Option or a Dependent Care Reimbursement Account Option.

(f)   If any claim for benefits under a Health Care Reimbursement Account Option or a Dependent Care Reimbursement Account Option is wholly or partially denied, the claimant shall be given notice in writing no later than forty-five (45) days after the claim is filed. The notice shall include the following information:

(1)   The specific reason for the denial;

(2)   Specific reference to the provisions used as the basis for the denial;

(3)   A description of any additional materials or information necessary for the claimant to perfect the claim and an explanation why such material or information is necessary;

(4)   An explanation that a full and fair review of the decision denying the claim may be requested in writing within ninety (90) days and with whom such request shall be filed; and

(5)   If such request is filed, the claimant or authorized representative may review pertinent documents and submit issues and comments in writing anytime during the ninety (90) days after notice of denial but before filing the request for hearing.

(g)   The request for a review of a denial of a claim for benefits under a Health Care Reimbursement Account Option or a Dependent Care Reimbursement Account Option shall be mailed or delivered to the Director at the address given in subchapter 3 of this chapter.

(h)   The EBD may contract with a claims administrator to process participant claims against health care spending accounts and dependent care spending accounts. The EBD and its claims administrator, if any, shall process claims according to subsection (f) of this section.

(i)   All hearings for review of the EBD or its hearing examiner conducted under this section shall be conducted no later than sixty (60) days after the EBD receives a request for a hearing. Upon notice of special circumstances by any party, the EBD may postpone the hearing but the hearing must be conducted within 120 days of the request for hearing.

[Source: Added at 31 Ok Reg 1358, eff 9-12-14]