OklahomaMedicaid contractors must use qualified reviewers for appeals
Starting November 1, 2026, Medicaid contractors must use qualified professionals to review appeals, and members or providers may seek a fair hearing after an appeal is upheld.
What it does
Medicaid contractors must have qualified professionals review appeals of their adverse decisions. They cannot use automated claim review for those appeals.
Providers have six months after receiving a claim denial to appeal. If the contractor upholds an adverse decision, the member or provider may ask the Oklahoma Health Care Authority for a fair hearing.
Argument forReview by an independent professional with relevant experience could help ensure appeal decisions consider the member’s condition and medical records.
Argument againstRequiring a reviewer with relevant training and experience may make it harder to find someone quickly, which could delay appeal decisions.
More detail
A Medicaid contracted entity must have a qualified professional review appeals of its adverse decisions and cannot use automated claim review for those appeals. These rules apply to appeals of adverse decisions made by a Medicaid contracted entity. A licensed physician reviews the appeal, or a licensed psychologist or other mental health professional when appropriate for the requested service. The reviewer must have a current, unrestricted U.S. license and relevant specialty training or experience. The reviewer cannot have made the original decision or have a financial interest in the appeal, and must consider relevant clinical information and records. These requirements take effect November 1, 2026.
A provider may appeal a claim denial within six months, and a member or provider may request a fair hearing after an appeal is upheld. The appeal period applies to providers seeking review of claim denials; the fair hearing option applies to members or providers after a contracted entity upholds an adverse decision. The six-month period starts when the provider receives the claim denial. A member or provider may ask the Oklahoma Health Care Authority for a fair hearing after receiving notice that the contracted entity upheld the adverse decision on appeal. These provisions take effect November 1, 2026. The provider’s six-month appeal period begins when the provider receives the claim denial.
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Where it stands
- Introduced
- Passed Senate
- Passed House
- To Governor
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2026
- May 13Approved by Governor Kevin Stitt 05/12/2026Became Law
- May 6Sent to GovernorTo Governor
- Vote recorded Third Reading. Result: pass.Lower
- May 6Signed, returned to Senate
- May 6Enrolled, to House
- May 6Referred for enrollment
- May 6Signed, returned to Senate
- May 6Third Reading, Measure passed: Ayes: 90 Nays: 2Major
- May 6General Order
- Apr 16CR; Do Pass Health and Human Services Oversight CommitteeMinor
- Apr 15
- Vote recorded Health And Human Services Oversight Committee: Do Pass. Result: pass.Lower
- Apr 1Policy recommendation to the Health and Human Services Oversight committee; Do Pass Public HealthMinor
- Vote recorded Public Health Committee: Do Pass. Result: pass.Lower
- Mar 30Referred to Public HealthMinor
- Mar 30Second Reading referred to Health and Human Services OversightMinor
- Mar 26First ReadingMinor
- Mar 26Engrossed to HousePassed House
- Mar 25Referred for engrossment
- Vote recorded Amendment. Result: pass.Upper
- Vote recorded Amendment. Result: pass.Upper
- Vote recorded Third Reading. Result: pass.Upper
- Vote recorded Advance. Result: pass.Upper
- Mar 25Measure passed: Ayes: 45 Nays: 0Passed Senate
- Mar 25Ayes: 42 Nays: 0
- Mar 25Advanced to Third Reading
- Mar 25Title restored
- Mar 25General Order, Amended
- Mar 24Coauthored by Representative Hasenbeck (principal House author)
- Feb 24Placed on General Order
- Feb 24Withdrawn from Appropriations committee
- Feb 16Referred to AppropriationsMinor
- Vote recorded Health & Human Services. Result: pass.Upper
- Feb 16Title stricken
- Feb 16Reported Do Pass as amended Health and Human Services committee; CR filedMinor
- Feb 3Second Reading referred to Health and Human Services Committee then to Appropriations CommitteeMinor
- Feb 2Remove as author Senator Rosino; authored by Senator Kern
- Feb 2Authored by Senator Rosino
- Feb 2First ReadingIntroduced
Healthcare