Okla. Admin. Code § 365:40-5-123

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

Section 365:40-5-123 - Reimbursement criteria

(a) An HMO that pays or reimburses claims shall disclose the criteria that establish how and whether a claim for services delivered by a participating or non-participating provider shall be paid. The disclosed criteria shall specify any documents required to be filed with a claim.

(b) If an HMO requires providers to use a uniform claim or billing form, the forms shall be either:

(1) The CMS-1500, or its successor, for outpatient billing and claim submission; or

(2) The UB-92, or its successor, for hospital billing and claim submission.

(c) An HMO shall furnish to providers the following information with the uniform claim or billing form:

(1) The amount the HMO shall pay the provider for the services rendered; and

(2) Notice that the provider shall bill the HMO directly for its portion of the charges if the subscriber has paid the applicable copayment or deductible.

(d) If an HMO requires the use of a claim transmittal form, the evidence of coverage shall include a convenient method for the subscriber to request the form. The form shall be sent to the subscriber within five (5) days after request.

(e) If an HMO uses reasonable and customary charge determinations to authorize settlements, it shall:

(1) Base such determinations on prevailing charges for health services and supplies common to a geographic area; and

(2) Furnish or arrange to furnish the rationale and data sources for a determination, within ten (10) days after receipt of a provider's request for this information and for no more than a nominal copying fee.

(f) A claim shall be reimbursed identically in amount whether a subscriber or provider submits the claim.

Okla. Admin. Code § 365:40-5-123

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