Okla. Admin. Code § 365:40-5-73

Current through Vol. 42, No. 8, January 2, 2025

Section 365:40-5-73 - Disenrollment for cause

An HMO may disenroll an individual member of a group for cause such as failure to pay premiums or copayments, fraud, or misuse of identification card or if the enrollee's behavior is abusive, disruptive, threatening, or uncooperative to the extent that continued membership in the HMO seriously impairs the HMO's ability to furnish services to either the enrollee or other enrollees. Before disenrolling the enrollee, the HMO shall:

(1) Make a serious effort to resolve the problem presented by the enrollee, including the use or attempted use of the HMO's grievance procedures;

(2) Ascertain that the enrollee's behavior does not directly result from an existing medical condition; and

(3) Document the problems, efforts, and medical conditions that demonstrate the HMO's conformity to this section.

Okla. Admin. Code § 365:40-5-73

Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04