Okla. Admin. Code § 317:2-1-2.6

Current through Vol. 42, No. 4, November 1, 2024

Section 317:2-1-2.6 - Continuation of benefits or services pending appeal

(a) In accordance with Section 431.230 of Title 42 of the Code of Federal Regulations, if an appellant submits a written request for a hearing within sixty (60) days of the notice of the adverse Agency action, the appellant may also request that existing benefits or services (hereinafter, collectively referred to as "services") be continued or reinstated until the earlier of dismissal of the appeal, appellant's withdrawal of the appeal, or an initial hearing decision adverse to the appellant.

(b) If the appellant fails to indicate a preference as to continuation or reinstatement of services in a written request for hearing made within sixty (60) days of the notice of the adverse Agency action, services shall be continued or reinstated. Provided, however, that a SoonerCare member shall not be entitled to continuation or reinstatement of services pending an appeal related to the following:

(1) When a service is denied because the member has exceeded the limit applicable to that service;

(2) When a request for a prior authorization is denied for a prescription drug. However:

(A) The Oklahoma Health Care Authority (OHCA) may authorize a single seventy-two (72) hour emergency supply of the drug, in accordance with Oklahoma Administrative Code (OAC) 317:30-577.2;

(B) A SoonerCare provider may initiate a step therapy exception request on behalf of a member, in accordance with OAC 317:30-5-77.4;

(3) When coverage of a prescription drug or service is denied because the requested drug or service is not a category or class of drugs or services covered by OHCA;

(4) When coverage for a prescription drug is denied because the Enrollee has been locked into one (1) pharmacy and the member seeks to fill a prescription at another pharmacy; or

(5) When a physician or other licensed health care practitioner has failed to prescribe or order the service or level of service for which continuation or reinstatement is requested.

Okla. Admin. Code § 317:2-1-2.6

Adopted by Oklahoma Register, Volume 37, Issue 22, August 3, 2020, eff. 7/1/2020

Adopted by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/1/2021

Amended by Oklahoma Register, Volume 40, Issue 16, May 1, 2023, eff. 7/1/2023

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024