SECTION 310:657-7-3. Operational requirements

(a)   The utilization review program shall have criteria that are based on evidence and regularly evaluated.

(1)   Practicing providers shall be involved in developing the review criteria.

(2)   After refusing to authorize a service, the Plan shall provide the review criteria for that service upon request to affected providers, the injured worker, and the Commissioner.

(b)   Qualified providers shall supervise the utilization review program. A licensed, board-certified clinical provider shall evaluate the appropriateness of any decision to deny a service to an injured worker.

(c)   Decisions on whether or not to authorize services shall be issued following the requirements of OAC 310:657-7-4.

(1)   Decisions shall be made using pertinent information and consulting with the treating provider.

(2)   The Plan shall ensure that reviewers consistently apply criteria.

(d)   The Plan shall routinely assess the effectiveness of the utilization review program.

(e)   Data systems shall be sufficient to support utilization review activities.

(f)   If the Plan delegates any activities to a utilization review organization, adequate oversight shall be maintained that includes:

(1)   A description of utilization review organization activities, including reporting requirements;

(2)   Formal approval of the utilization review organization's program by the Plan; and

(3)   Evaluations of the utilization review organization.

(g)   Utilization review shall be coordinated with other medical management activities.

(h)   The Plan or its utilization review organization shall provide toll-free telephone access to its staff during normal business hours.

(i)   When conducting utilization review, the Plan or utilization review organization shall collect only information necessary for assessing the appropriateness of, and need for, services.

[Source: Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok Reg 2404, eff 6-25-06]