SECTION 260:50-5-11. Covered charges

  Items which will be considered for payment under HealthChoice will be referred to as covered charges that are medically necessary. Specific criteria and limitations apply. Covered charges may include:

(1)   Hospital services;

(2)   Provider's services;

(3)   Skilled Nurse facility expense;

(4)   Skilled nurse care;

(5)   Dentist's or oral surgeon's services;

(6)   Oral surgery;

(7)   Rehabilitative care;

(8)   Outpatient expense; and

(9)   Hospice care.

(10)   Approval of exceptional claims.

(A)   EGID's Health Care Management Unit may recommend exceptions to the benefits provided by HealthChoice for situations which would otherwise be denied or subject to limited coverage.

(B)   Each request for exception must first be reviewed by the Health Care Management Unit on an individual basis. All responsibility for providing the documentation necessary to complete the review falls to the member. Recommendations will then be given to the Medical Director and Administrator both of whom must review all requested exceptions. Exceptions that have been reviewed but not approved in writing by the Medical Director and Administrator are deemed not approved. Approval of exceptions shall not establish precedent for other requests. All requests shall confirm that the requested exception is:

(i)   medically necessary, and

(ii)   within the standards of the community, and

(iii)   cost effective, and/or

(iv)   in compliance with all criteria as established by the Medical Director or designee.

(11)   Facility of benefit payment. Whenever payments which should have been made under this plan in accordance with this section have been made under any other plans, EGID shall have the right, exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of this section, and amounts so paid shall be deemed to be benefits paid under this plan and, to the extent of such payments, EGID shall be fully discharged from liability under this plan.

(12)   Right of recovery. Whenever payment has been made by EGID with respect to allowable expenses in a total amount, at any time, in excess of the maximum amount of payment necessary at that time to satisfy the intent of this section, EGID shall have the right to recover such payments, to the extent of such excess, from among one or more of the following, as EGID shall determine:

(A)   any persons to or for or with respect to whom such payments were made;

(B)   any other insurers; or

(C)   service plans or any other organizations.

[Source: Added at 31 Ok Reg 1390, eff 9-12-14; Amended at 36 Ok Reg 1620, eff 1-1-20]