Review of appeals — Qualifications of reviewers

A utilization review entity shall ensure that all appeals are

reviewed by a physician, pharmacist, or licensed mental health

professional. The physician, pharmacist, or licensed mental health

professional shall:

Oklahoma Statutes - Title 36. Insurance Page 1319

1. Possess a current and valid unrestricted license in any

United States jurisdiction;

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

pharmacist, 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, pharmacist, or

licensed mental health professional to determine if

the service or procedure is medically necessary or

clinically appropriate,

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, or for appeals coming

from a pharmacist, which may be conducted by another licensed

pharmacist 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.