Protecting the legal rights of our members is a priority.
When it comes to protecting your legal rights, HealthChoice makes it a priority. You have rights under Federal and Oklahoma State law as well as various regulations. Below are details on these enumerated rights and what our members can do to exercise them.
If your claim is denied in whole or in part for any reason, either you, your attorney, or your authorized provider can request that the claim be reviewed by submitting a written request to the HealthChoice Appeals Unit.
Active, Pre-Medicare and Medicare without Part D prior authorization and appeals
When your pharmacy claims are denied, you may have the right to appeal the denial of these claims. There is a review process that is required for coverage of certain medications such as those that:
- Are high cost.
- Have specific prescribing guidelines.
- Are generally used for cosmetic purposes.
- Are limited in quantities.
Oklahoma privacy laws and the federal Health Insurance Portability and Accountability Act of 1996 protect the privacy of an individual’s health information. For HIPAA purposes, OMES has designated itself as a hybrid entity. This means that HIPAA only applies to areas of OMES operations involving health care, and not to all lines of service offered by OMES.
HealthChoice is licensed by the Oklahoma Insurance Commission to provide utilization review services. Our Utilization Review Plan is updated on an annual basis to reflect changes in policies and procedures.
HealthChoice provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). HealthChoice provides free language services to people whose primary language is not English, such as qualified interpreters. If you need these services, contact HealthChoice Member Services at 800-752-9457 (TDD: 866-447-0436).