Okla. Admin. Code § 810:15-5-4

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

Section 810:15-5-4 - Medical Interlocutory Order

(a) The purpose of this Section is to provide a prescribing doctor or pharmacy an ability to obtain a medical interlocutory order (MIO) in instances where preauthorization denials of a previously prescribed and dispensed drug excluded from the closed formulary poses an unreasonable risk of a medical emergency as defined in 810:15-1-2.

(b) An MIO will be issued if the request for an MIO contains the following information:

(1) injured employee name;

(2) date of birth of injured employee;

(3) prescribing doctor's name;

(4) name of drug and dosage;

(5) MIO requestor's name (pharmacy or prescribing doctor);

(6) MIO requestor's contact information;

(7) a statement that a preauthorization request for a previously prescribed and dispensed drug, which is excluded from the closed formulary, has been denied by the insurance carrier;

(8) a statement that the preauthorization denial poses an unreasonable risk of a medical emergency as defined in 810:15-1-2;

(9) a statement that the potential medical emergency has been documented in the preauthorization process;

(10) a statement that the insurance carrier has been notified that a request for an MIO is being submitted to the Commission; and

(11) a signature and the following certification by the MIO requestor for Paragraphs (7) through (11) of this Subsection, "I hereby certify under penalty of perjury that the previously listed conditions have been met."

(c) A complete request for an MIO under this Section shall be processed and approved by the Commission in accordance with this Section. At the discretion of the Commission, an incomplete request for an MIO under this Section may be considered in accordance with this Section.

(d) The request for an MIO may be submitted on the designated Commission form. The form is available on the Commission's website, http://www.wcc.ok.gov. If the Commission form is not available, the written request must contain the provisions of Subsection (b) of this Section.

(e) The MIO requestor shall provide a copy of the MIO request to the insurance carrier, prescribing doctor, injured employee, and dispensing pharmacy, if known, on the date the request for MIO is submitted to the Commission.

(f) An approved MIO shall be effective retroactively to the date the complete request for an MIO is received by the Commission.

(g) The MIO shall continue in effect until the later of:

(1) final adjudication of a medical dispute regarding the medical necessity and reasonableness of the drug contained in the MIO;

(2) expiration of the period for a timely appeal; or

(3) agreement of the parties.

(h) A party shall comply with an MIO entered in accordance with this Section and the insurance carrier shall reimburse the pharmacy for prescriptions dispensed in accordance with an MIO.

(i) The insurance carrier shall notify the prescribing doctor, injured employee, and the dispensing pharmacy once reimbursement is no longer required in accordance with Subsection (g) of this Section.

(j) A party may seek to dispute, reverse or modify an MIO issued under this Section by filing a written request for a hearing before an Administrative Law Judge of the Commission.

Okla. Admin. Code § 810:15-5-4

Adopted by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015