SECTION 260:45-5-1. Request for hearing

(a)   Grievances. EGID has established procedures by which:

(1)   Independent Review Organizations shall act as an appeals body for complaints by insured members regarding adverse benefit determinations based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit,

(2)   A three [3] member Grievance Panel shall act as an appeals body for complaints by insured members regarding all other issues.

(b)   Court Administrator Appointees. The Court Administrator shall designate Grievance Panel members as shall be necessary. The members of the Grievance Panel shall consist of two [2] Attorneys licensed to practice law in this state and one [1] state licensed health care professional or health care administrator who has at least three [3] years practical experience, has had or has admitting privileges to a State of Oklahoma hospital, has a working knowledge of prescription medication, or has worked in an administrative capacity at some point in their career.

(c)   Governor Appointees. The state health care professional shall be appointed by the Governor. At the Governor's discretion, one or more qualified individuals may also be appointed as an alternate to serve on the Grievance Panel in the event the Governor's primary appointee becomes unable to serve.

(d)   Right to a Hearing. Any covered member who has exhausted EGID's internal review procedures and has timely requested in writing a hearing before the Grievance Panel pursuant to 260:45-5-1(a)(2) shall receive a hearing in person or through licensed counsel before the panel.

(e)   Remedy. Grievance procedures conducted by the three [3] member Grievance Panel shall be subject to the Oklahoma Administrative Procedures Act, including provisions thereof for review of agency decisions by the district court.

(f)   Failure to timely submit hearing request. All Grievance Panel requests must be filed within sixty [60] days from the date the member is notified that the member's claim, benefit, coverage, or other matter has been denied and that EGID's internal review procedures have been exhausted. After more than sixty [60] days from the date the member was first notified that the member's claim, benefit, coverage, or other matter has been denied and that EGID's internal review procedures have been exhausted, the matter shall be deemed finally resolved.

(g)   Aggrieved member covered by an HMO. Any member covered by an HMO is entitled to a hearing before the Panel in the same manner as all other covered members for those matters not covered by an Independent Review Organization. The member must exhaust the HMO's internal grievance procedure, except for an emergency or if the HMO fails to timely respond, before requesting a Grievance Panel hearing. The member must file, along with his request for hearing, a written certification from the HMO that the member has exhausted said procedure, or a detailed explanation of the emergency or of the HMO's failure to respond.

(h)   Submission of Grievance request. Any Grievance request shall be in writing on a form provided by EGID for such purpose or in writing by the employee if in substantial compliance with the form and shall contain the following information:

(1)   Name of employee, Social Security Number and address;

(2)   Name of dependent for whom claim was submitted, if not the covered employee;

(3)   Name of employee's employing entity, location, and identifying number;

(4)   Nature of claim: Health, Dental, Life, Eligibility, Disability, HIPAA or HMO;

(5)   Date claim submitted for payment, claim number;

(6)   The reason given, if any, by the claims administration contractor for denying the claim in whole or in part; and

(7)   A short statement as to the nature of the illness or injury giving rise to the claim.

(i)   Mailing address for submission of Request for Hearing. The Request for Hearing shall be mailed or delivered to EGID to the attention of Attorney - Grievance Procedures, at 3545 N. W. 58th Street, Suite 600, Oklahoma City, Oklahoma 73112.

[Source: Added at 31 Ok Reg 1386, eff 9-12-14; Amended at 34 Ok Reg 1248, eff 1-1-18; Amended at 35 Ok Reg 1350, eff 1-1-19; Amended at 36 Ok Reg 1618, eff 1-1-20; Amended at 37 Ok Reg 1333, eff 9-11-20]