Adverse determinations to be made by physician or

licensed mental health professional.

A utilization review entity shall ensure that all adverse

determinations are made by a physician or licensed mental health

professional. The physician or licensed mental health professional

shall:

1. Possess a current and valid nonrestricted license in any

United States jurisdiction;

2. Have the appropriate training, knowledge, or expertise to

apply appropriate clinical guidelines to the health care service

being requested; and

3. Make the adverse determination under the clinical direction

of one of the utilization review entity's medical directors who is

responsible for the provision of reviewing health care services to

enrollees of Oklahoma. All such medical directors must be

physicians licensed in any United States jurisdiction.