SB 1553

                      An Act
ENROLLED SENATE
BILL NO. 1553  By: Kern of the Senate
                                                 and
                                          Hasenbeck of the House
       An Act relating to the state Medicaid program;
       amending 56 O.S. 2021, Section 4002.8, as last
       amended by Section 3, Chapter 372, O.S.L. 2025 (56
       O.S. Supp. 2025, Section 4002.8), which relates to
       review and appeal of adverse determinations;
       specifying qualifications for psychologist reviewing
       appeal; updating statutory language; and providing an
       effective date.
SUBJECT:   Medicaid contracted entity appeals
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
    SECTION 1.     AMENDATORY     56 O.S. 2021, Section 4002.8, as
last amended by Section 3, Chapter 372, O.S.L. 2025 (56 O.S. Supp.
2025, Section 4002.8), is amended to read as follows:
    Section 4002.8. A. A contracted entity shall utilize uniform
procedures established by the Oklahoma Health Care Authority under
subsection B of this section for the review and appeal of any
adverse determination by the contracted entity sought by any member
or provider adversely affected by such determination.
    B. The Authority shall develop procedures for members or
providers to seek review by the contracted entity of any adverse
determination made by the contracted entity.
    C. A provider shall have six (6) months from the receipt of a
claim denial to file an appeal.
    D. A contracted entity shall ensure that all appeals of adverse
determinations made by the contracted entity are reviewed by a
licensed physician or, if appropriate for the requested service, a
licensed psychologist or mental health professional. The contracted
entity shall not use any automated claim review software or other
automated functionality for such appeals.
    E. The physician, psychologist, or other mental health
professional who reviews the appeal 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,
psychologist, or other mental health professional who typically
manages the medical condition or disease. This requirement shall be
considered met:
        a.   for a physician, if:
             (1)      the physician maintains board certification for
                      the same or similar specialty as the medical
                      condition in question, or
             (2)      the physician’s training and experience:
                      (a)   includes treatment of the condition,
                      (b)   includes treatment of complications that may
                            result from the service or procedure, and
                      (c)   is sufficient for the physician to determine
                            if the service or procedure is medically
                            necessary or clinically appropriate, or
        b.   for a psychologist, if:
             (1)      the psychologist is currently licensed in
                      accordance with the Psychologists Licensing Act,
ENR. S. B. NO. 1553  Page 2
                (2)   the psychologist has training and experience in
                      the testing for and treatment of the condition,
                      and
                (3)   the psychologist’s training and experience is
                      sufficient to determine if the service is
                      medically necessary or clinically appropriate, or
        c.      for a mental health professional other than a
                psychologist, if the mental health professional’s
                training and experience:
                (1)   includes treatment of the condition, and
                (2)   is sufficient for the mental health professional
                      to determine if the service is medically
                      necessary or clinically appropriate;
    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 any
medical records pertinent to the active condition that are provided
to the contracted entity by the member’s provider, or a health care
facility, and any pertinent medical literature provided to the
contracted entity by the provider.
    F. Upon receipt of notice from the contracted entity that the
adverse determination has been upheld on appeal, the member or
provider may request a fair hearing from the Authority. The
Authority shall develop procedures for fair hearings in accordance
with 42 C.F.R., Part 431.
   SECTION 2.     This act shall become effective November 1, 2026.
ENR. S. B. NO. 1553  Page 3
   Passed the Senate the 25th day of March, 2026.
                                   Presiding Officer of the Senate
   Passed the House of Representatives the 6th day of May, 2026.
                                    Presiding Officer of the House
                                                of Representatives
                       OFFICE OF THE GOVERNOR
   Received by the Office of the Governor this ____________________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________
   Approved by the Governor of the State of Oklahoma this _________
day of ___________________, 20_______, at _______ o'clock _______ M.
                                   _________________________________
                                   Governor of the State of Oklahoma
                  OFFICE OF THE SECRETARY OF STATE
   Received by the Office of the Secretary of State this __________
day of __________________, 20 _______, at _______ o'clock _______ M.
By: _________________________________
ENR. S. B. NO. 1553  Page 4