SECTION 310:657-7-4. Utilization review decision

(a)   The Plan shall complete any individual decision to authorize or deny a non-emergency service within two (2) working days after obtaining all necessary information. Necessary information includes any clinical evaluation of an injured worker by a provider other than the one originally recommending a proposed service.

(b)   The Plan shall notify the provider by telephone within twenty-four (24) hours after the decision to authorize or deny a service. The Plan shall send confirmation of the decision within two (2) working days after deciding.

(c)   If the injured worker is an inpatient or undergoing treatment, the Plan shall communicate to the provider any decision to authorize or deny the service by telephone within twenty-four (24) hours after the decision. The Plan shall send confirmation to the provider within two (2) working days after deciding. A decision on an extended stay shall identify the additional number of days or services approved.

(d)   A decision to authorize or deny coverage for an emergency service shall be based on the patient's presenting symptoms.

[Source: Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff 6-25-06]