SECTION 365:10-1-36. Claims processing

(a)   A health care practitioner or hospital shall file a claim in a manner consistent with the requirements of this Part and in accordance with nationally recognized standards.

(b)   A third party payor shall accept a form which is submitted in compliance with this Part for the processing of the third party payor's claims.

(c)   When the legitimacy or appropriateness of the health care service is disputed, a third party payor may request additional medical information that describes and summarizes the diagnosis, treatment, and services rendered to the insured, member, or subscriber.

(d)   All third party payors may obtain additional claims information, when necessary to determine eligibility for benefits or for determination of coverage, subject to the following:

(1)   third insured, member or subscriber,

(2)   the employer of the insured, member or subscriber, or

(3)   any other non-provider third party.

(e)   All claims are subject to 36 O.S. §1219.

(f)   All health care practitioners and hospitals shall:

(1)   Use the most current edition of the HCFA Form 1500, HCFA Form UB-82, HCFA Form UB-92, ADA-1990 Dental Claim Form, or Universal Prescription Drug Claim Form and most current instructions for these forms in the filing of claims with third party payors.

(2)   Modify their billing practice to encompass the current coding changes by the effective date of the changes set forth by the developers of the forms, codes, and procedures required by this Part.

(g)   This Part is applicable to any claim received by a third party payor on or after July 1, 1994.

[Source: Added at 11 Ok Reg 3295, eff 7-1-94]