justicedao/ipfs_state_laws huggingface dataset:
836-053-1130 Annual Summary, Utilization Review (1) To comply with the requirements of ORS 743.807, an insurer must electronically submit on or before June 30 of each calendar year, an annual utilization review program summary for the preceding calendar year to the Division of Financial Regulation in the format required by the director of the Department of Consumer and Business Services as set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. Filing and reporting requirements in this rule apply to: (a) A domestic insurer; and (b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of a required report. (2) For calendar year 2014 and each subsequent calendar year the annual summary required by section (1) of this rule must: (a) Describe the insurer’s utilization review policies ; (b) Provide a summary of established processes and monitoring activities for each of the following program areas: (A) Program oversight; (B) Utilization review criteria development, implementation and revision; (C) List of clinical information, research publications and other information used in the development of pre-service authorization requirements, concurrent review and other utilization review activities; (D) Provider program participation procedures; (E) Minimum qualifications of utilization review decision makers; (F) Time frames for utilization review decisions; (G) Enrollee and provider communication processes; and (H) Program monitoring, review, evaluation and update; and (c) Document: (A) Delegated utilization review activities, including monitoring and oversight activities of those to whom the activities are delegated; and (B) Policies for review and audit of delegates and delegated activities. (3) To minimize duplicative reporting requirements, an insurer may meet the reporting requirements of this rule by submitting to the department either of the following: (a) A copy of a report prepared for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required. (b) An addendum to an annual filing of the immediately preceding year: (A) Stating, if applicable, that no information has changed since the previous annual filing; or (B) Identifying, if applicable, only the information that has changed since the previous annual filing. (4) An insurer may not submit addenda described in subsection (3)(b) of this rule in two consecutive years. (5) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities. Statutory/Other Authority: ORS 731.244 & 743.819 Statutes/Other Implemented: ORS 743.801, 743.804 & 743.807 History: ID 20-2023, minor correction filed 06/27/2023, effective 06/27/2023 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1140 Appeal and Utilization Review Determinations (1) When a provider first appeals an insurer denial described in ORS 743.807(2)(c): (a) The insurer must acknowledge receipt of the notice of appeal not later than the seventh day after receiving the notice; and (b) An appropriate medical consultant or peer review committee must review the appeal and decide the issue not later than the 30th day after the insurer receives notice of the appeal. (2) A standard for timeliness in section (1) of this rule does not apply when: (a) The period of time is too long to accommodate the clinical urgency of the situation; (b) The provider does not reasonably cooperate; or (c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise. (3) An insurer must treat an appeal from a decision by a medical consultant or peer review committee pursuant to section (1)(b) of this rule as an internal appeal under the insurer’s grievance procedures. (4) Nothing in this rule prevents an enrollee from filing an internal appeal under the insurer’s regular grievance procedure established pursuant to ORS 743.804 when the grievance concerns an adverse benefit determination, but this rule does not entitle a person not otherwise allowed to file a grievance a decision by a medical consultant or peer review committee to file such a grievance. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.804, 743.806 & 743.807 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1180 Format and Instructions for Report Required by ORS 743.818 (1) As used in this rule: (a) “Covered lives” means Oregon residents who are employees, dependents of employees, or individuals otherwise eligible for an individual, student health, association, group, or self-insured group health benefit plan or other benefit plan for which reporting is required and who are enrolled for coverage under the terms of the plan as of the close of the calendar quarter. (b) “Carrier” has the meaning given that term in ORS 743.730(7). (c) “Zip code” means the 5-digit code: (A) Of the employee or individual policyholder’s Oregon residence; (B) Of an Oregon employer group covered by a stop loss policy; or, (C) In circumstances for which no Oregon zip codes exists, the placeholder code established by the director of the Department of Consumer and Business Services set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. (2) At quarterly intervals covering each year, a carrier authorized to transact health insurance in Oregon must submit information pertaining to covered lives through the reporting system of the Division of Financial Regulation in the format established by the director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. The carrier must submit the required information on or before: (a) May 1 for the first calendar quarter. (b) August 1 for the second calendar quarter. (c) November 1 for the third calendar quarter. (d) February 1 for the fourth calendar quarter. (3) A carrier claiming exemption from reporting must request an exemption through the reporting system of the Division of Financial Regulation on or before the due date for the calendar quarter for which reporting is first due. (4) A carrier submitting information pertaining to covered lives or requesting an exemption from reporting is subject to the electronic reporting or response requirements of OAR 836-011-0005. Statutory/Other Authority: ORS 731.244, 743.745 & ORS 743.818 Statutes/Other Implemented: ORS 743.818 History: ID 21-2023, minor correction filed 06/27/2023, effective 06/27/2023 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14
836-053-1300 Purpose and Scope; Application (1) OAR 836-053-1300 to 836-053-1365 are adopted by the Director of the Department of Consumer and Business Services to implement ORS 743B.252 to 743B.256, governing the Director’s contracting with independent review organizations for the purpose of resolving disputes relating to adverse decisions by insurers in one or more of the issues specified in 743B.252. (2) OAR 836-053-1300 to 836-053-1365 are operative with respect to disputes for which the initial grievance is filed on or after July 1, 2002 under health benefit plans in existence, issued or renewed on or after July 1, 2002. Statutory/Other Authority: ORS 731.244 & 743B.253 - 743B.256 Statutes/Other Implemented: ORS 743B.252 - 743B.256 History: ID 11-2018, minor correction filed 08/03/2018, effective 08/03/2018 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1305 Definitions; Authority to Act for Enrollee (1) As used in OAR 836-053-1300 to 836-053-1365, "medical reviewer" means any of the following persons who is assigned to an independent review case by an independent review organization: (a) A doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the laws of another state. (b) A provider as defined in ORS 743B.001(16)(a)(b). (c) A health care professional licensed, certified or otherwise authorized or permitted by the laws of another state to administer medical or mental health services in the ordinary course of business or practice of a profession. (2) An action that may be taken by an enrollee under ORS 743B.252 to 743B.256 or under OAR 836-053-1300 to 836-053-1365 may be taken on behalf of the enrollee by a representative of the enrollee. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 - 743B.256 Statutes/Other Implemented: ORS 743B.252 - 743B.256 & ORS 743B.001 History: ID 14-2018, minor correction filed 08/20/2018, effective 08/20/2018 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1315 Performance Criteria The following are performance criteria that an independent review organization must satisfy when demonstrating its eligibility for contracting with the Director of the Department of Consumer and Business Services to perform independent review responsibilities under ORS 743B.256, and in order to continue performing those responsibilities under the contract with the director. For purposes of this rule, an independent review organization must: (1) Demonstrate its capability of and expertise in reviewing health care, and a history of such review, in terms of the coverage issues that are subject to independent review pursuant to ORS 743B.252, in terms of the application of other health plan coverage provisions and in terms of health insurance contract law. (2) Demonstrate the ability to handle a full range of review cases occurring in this state. An independent review organization may contract with a more specialized review organization, but the independent review organization must ensure that each review conducted meets all the requirements of ORS 743B.252, 743B.253 and 743B.256 and OAR 836-053-1300 to 836-053-1365. (3) Comply with all conflict of interest provisions in OAR 836-053-1320. (4) Maintain and assign an adequate number and range of qualified medical reviewers in compliance with OAR 836-053-1310 and 836-053-1315 in order to: (a) Make determinations regarding the full range of independent review cases occurring in this state under ORS 743B.252; and (b) Meet timelines specified in ORS 743B.256 and OAR 836-053-1340, including timelines for expedited review. (5) Conduct reviews, reach determinations and document determinations consistent with OAR 836-053-1325 and 836-053-1330. (6) Maintain administrative processes and capabilities in compliance with OAR 836-053-1325 and 836-053-1330. Statutory/Other Authority: ORS 731.244, ORS 743B.256 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.256 & ORS 743B.253 History: ID 16-2018, minor correction filed 08/20/2018, effective 08/20/2018 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1317 Professional Qualifications (1) A doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the laws of another state that govern the licensing of doctors of medicine or osteopathy shall be responsible for each final independent review determination made by an independent review organization, and in making a determination shall consult with other medical reviewers as appropriate. (2) An independent review organization shall have a medical director who holds a current unrestricted license as a medical doctor or osteopathic physician and has had experience in direct patient care. The medical director shall provide guidance for clinical aspects of the independent review process and oversee the independent review organization's quality assurance and credentialing programs. (3) An independent review organization shall maintain policies and practices that assure that each medical reviewer: (a) Holds a current, unrestricted license, certification or registration in this state, or current, unrestricted credentials from another state; (b) Has at least five years of recent clinical experience; (c) Is certified by an appropriate member board of the American Board of Medical Specialties if board certification is available for the specialty or profession in which the medical reviewer is engaged; and (d) Has the ability to apply scientific standards of evidence in judging research literature pertinent to review issues, as demonstrated through relevant training or professional experience. (4) A medical reviewer who is assigned to a case must have at least five years of recent clinical experience dealing with the same health conditions under review or similar conditions. Exceptions may be made to this requirement in unusual situations when the only experts available for a highly specialized review are in academic or research work and do not meet the clinical experience requirement. (5) An independent review organization must maintain a training program for staff and medical reviewers, addressing at least: (a) Confidentiality; (b) Neutrality and conflict of interest; (c) Appropriate conduct of reviews; and (d) Documentation of evidence for determination. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253 History: ID 17-2018, minor correction filed 08/20/2018, effective 08/20/2018 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1320 Conflict of Interest (1) An independent review organization: (a) Must not be a subsidiary of, or in any way owned or controlled by, an insurer or an association of insurers or of doctors, providers or other health care professionals; (b) Must provide information to the Director of the Department of Consumer and Business Services on its own organizational affiliations and potential conflicts of interest at the time of its response to the director's request for proposals and thereafter when material changes occur; (c) Must immediately turn down a case referred by the director if accepting it would constitute an organizational conflict of interest; and (d) Must ensure that medical reviewers are free from any actual or potential conflict of interest in assigned cases. (2) In connection with a case, neither an independent review organization nor any of its medical reviewers may have any material professional, familial or financial affiliation with the health insurer, enrollee, enrollee's provider, that provider's medical or practice group, the facility at which the service would be provided or the developer or manufacturer of a drug or device under review. For the purpose of this section, an affiliation with any director, officer or executive of an independent review organization shall be considered to be an affiliation with the independent review organization. (3) Except as provided in section (4) of this rule, the following do not constitute violations of this rule: (a) Staff affiliation with an academic medical center or National Cancer Institute-designated clinical cancer research center; (b) Staff privileges at a health facility; or (c) An independent review organization's receipt of an insurer's payment for independent reviews assigned by the director. (4) A potential medical reviewer shall be considered to have a conflict of interest in connection with a case with regard to a facility or health plan, regardless of revenue from that source, if the potential reviewer is a member of a standing committee of the facility or the health plan, or a provider or other health care professional network that contracts with the health plan. (5) A conflict of interest may be waived only if both the enrollee and the health plan agree in writing after receiving full disclosure of the conflict, and only if: (a) The conflict involves a medical reviewer, and no alternate reviewer with necessary special expertise is available; or (b) The conflict involves an independent review organization and the director determines that seeking a waiver of conflict is preferable to reassigning the dispute to a different independent review organization. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253 History: ID 18-2018, minor correction filed 08/20/2018, effective 08/20/2018 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1330 Criteria and Considerations for External Review Determinations (1) The following criteria and considerations apply to decisions by an independent review organization: (a) An independent review organization must use fair procedures in making a decision, and the decision must be consistent with the standards in ORS 743B.253 and 743B.256 and OAR 836-053-1300 to 836-053-1365. (b) An independent review organization may override the standards of a health benefit plan governing the coverage issues that are subject to independent review pursuant to ORS 743B.252(1) only if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice. (2) A decision by an independent review organization of a dispute relating to an adverse decision by an insurer is subject to enforcement under ORS 743B.252 to 743B.258 if: (a) The dispute relates to an adverse decision on one or more of the following: (A) Whether a course or plan of treatment is medically necessary; (B) Whether a course or plan of treatment is experimental or investigational; or (C) Whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743B.225 ; and (b) The decision by the independent review organization is made in accordance with the coverage described in the health benefit plan, including limitations and exclusions expressed in the plan, except that the independent review organization may override the insurer's standards for medically necessary or experimental or investigational treatment, if the independent review organization determines that: (A) The standards of the insurer are unreasonable or are inconsistent with sound medical practice; or (B) For cases in which the insurer's decision addressed whether a course or plan of treatment was medically necessary: (i) The insurer's decision did not conform to the insurer's definition of medically necessary in the relevant health insurance policy, or (ii) The insurer's decision did not conform to the requirement that the definition of medical necessity be uniformly applied; or (C) For cases in which the insurer's decision addressed whether a course or plan of treatment was experimental or investigational: (i) The insurer's decision did not conform to the insurer's definition of experimental or investigational in the relevant health insurance policy, or (ii) The insurer's decision did not conform to the requirement that the definition of experimental or investigational be uniformly applied. (3) No provision of OAR 836-053-1300 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253, ORS 743B.225, ORS 743B.252, ORS 743B.256 & ORS 743B.258 History: ID 20-2018, minor correction filed 08/21/2018, effective 08/21/2018 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 13-2006, f. 7-14-06 cert. ef. 1-1-07 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1335 Procedures for Complaint Investigation (1) The Director of the Department of Consumer and Business Services may audit, examine and conduct an on-site review of records to investigate complaints alleging that an independent review organization or medical reviewer committed conduct contrary to ORS 743B.253 or 743B.256, or OAR 836-053-1300 to 836-053-1365 or the contract between the director and the independent review organization. (2) In addition to the procedures for an enrollee to submit information about an independent review organization’s decision in OAR 836-053-1325, a person, including, but not limited to, an enrollee, insurer or provider, may submit a written complaint to the director alleging that an independent review organization committed conduct described in this rule. The director may consider the complaint in relation to the terms of the contract with the independent review organization and in relation to ORS 743B.253 or 743B.256 and OAR 836-053-1300 to 836-053-1365 and take action as appropriate under the contract. The director shall notify the complainant of the results of the director's determinations and of any action taken or to be taken. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253 & ORS 743B.256 History: ID 21-2018, minor correction filed 08/21/2018, effective 08/21/2018 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1337 Preliminary Review by Insurer When an enrollee applies to an insurer for independent review of a dispute, the insurer shall review the application and advise the enrollee that the application does or does not meet any of the criteria for independent review. The insurer shall send the application to the independent review organization as provided in ORS 743B.252 unless the enrollee withdraws the application. Statutory/Other Authority: ORS 731.244 & OR 743B.253 Statutes/Other Implemented: ORS 743B.255 History: ID 22-2018, minor correction filed 08/21/2018, effective 08/21/2018 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02
836-053-1342 Timelines and Notice for Expedited Decision-Making (1) When an insurer expedites an enrollee's case under ORS 743B.252(5), the insurer shall inform the Director of the Department of Consumer and Business Services and the independent review organization that the referral is expedited. If information on whether a referral is expedited is not provided to the independent review organization, the independent review organization may presume that the referral is not an expedited review, but the independent review organization may request clarification from the insurer. (2) The insurer and the director must expedite an external review that is required to be expedited under ORS 743B.252(5) when: (a) An enrollee requests external review before the enrollee has exhausted all internal appeals; or (b) An enrollee simultaneously requests an expedited internal appeal and an expedited external review. (3) An independent review organization shall make its decision in each expedited case within a time period that is appropriate for accommodating the clinical urgency of the particular case, but in any event not exceeding the maximum time period specified in ORS 743B.256(3). (4) In an expedited case, an independent review organization shall immediately provide notice to enrollees and the insurer of the result and basis for the decision as provided in OAR 836-053-1325. Statutory/Other Authority: ORS 731.244, ORS 743B.253 & ORS 743B.256 Statutes/Other Implemented: ORS 743B.253, ORS 743B.256 & ORS 743B.252 History: ID 24-2018, minor correction filed 08/22/2018, effective 08/22/2018 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11 ID 19-2002, f. 9-27-02, cert. ef. 9-28-02 ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02