Appeals to be reviewed by physician or licensed mental

health professional.

A utilization review entity shall ensure that all appeals are

reviewed by a physician or licensed mental health professional. The

physician or licensed mental health professional shall:

1. Possess a current and valid unrestricted license in any

United States jurisdiction;

2. Be of the same or similar specialty as a physician or

licensed mental health professional who typically manages the

medical condition or disease, which means that the physician either

maintains board certification for the same or similar specialty as

the medical condition in question or whose training and experience:

a. includes treating the condition,

b. includes treating complications that may result from

the service or procedure, and

c. is sufficient for the physician or licensed mental

health professional to determine if the service or

procedure is medically necessary or clinically

appropriate,

Oklahoma Statutes - Title 36. Insurance Page 1311

except for appeals coming from a licensed mental health

professional, which may be conducted by another licensed mental

health professional as opposed to a physician;

3. Not have been directly involved in making the adverse

determination;

4. Not have any financial interest in the outcome of the

appeal; and

5. Consider all known clinical aspects of the health care

service under review, including, but not limited to, a review of

those medical records which are pertinent and relevant to the active

condition provided to the utilization review entity by the

enrollee's health care provider, or a health care facility, and any

pertinent medical literature provided to the utilization review

entity by the health care provider.