justicedao/ipfs_state_laws huggingface dataset:
836-053-1345 Quality Assurance Mechanisms (1) An independent review organization must have a quality assurance program that ensures the timeliness, quality of review and communication of determinations to enrollees and insurers. The program must also ensure the qualifications, impartiality and freedom from conflict of interest of the organization, its staff and medical reviewers. The quality of review of an independent review organization includes the use of appropriate methods to match the case, confidentiality and systematic evaluation of complaints for patterns or trends. (2) A quality assurance program must include a written plan addressing its scope and objectives; program organization, monitoring and oversight mechanisms; and evaluation and organizational improvement of independent review organization activities. Organizational improvement must include the implementation of action plans to improve or correct identified problems, and communication of the results of action plans to staff and medical reviewers. (3) An independent review organization shall record complaints in a log. The log shall include for each complaint the nature of the complaint and how it was resolved. Upon request, the independent review organization shall provide the log and complaints to the director for review. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253 History: ID 25-2018, minor correction filed 08/22/2018, effective 08/22/2018 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
836-053-1350 Ongoing Requirements for Independent Review Organizations (1) An independent review organization shall file an annual statistical report with the Director of the Department of Consumer and Business Services, on a form specified by the director, that summarizes reviews conducted. The report shall include, but need not be limited to, volumes, types of cases, compliance with timelines for expedited and non-expedited cases, determinations, number and nature of complaints and compliance with conflict of interests rules. (2) An independent review organization shall submit updated information to the director if at any time there is a material change in the information included in the response of the independent review organization to the director's request for proposals. (3) An independent review organization shall maintain records of all materials, including materials submitted by all parties, notifications, documents relied upon, and the independent review organization’s ultimate decision for a period of not less than three years after any review. The independent review organization shall provide copies of any of these documents to the director upon request. Statutory/Other Authority: ORS 731.244, ORS 743B.252, ORS 743B.253 & ORS 743B.256 Statutes/Other Implemented: ORS 743B.253 & ORS 743B.256 History: ID 26-2018, 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
836-053-1355 Synopses (1) The synopses of decisions required to be filed by independent review organizations under ORS 743B.256(5) with the Director of the Department of Consumer and Business Services must meet the requirements of this rule. (2) Synopses of decisions shall include the following for each decision: (a) A description of the dispute sought to be reviewed by the independent review organization, including whether the dispute is alleged to concern the determination of medical necessity or experimental or investigational treatment, whether an active course of treatment is occurring for the purpose of determining whether a person is eligible for continuity of care, or whether the dispute concerns some other issue. (b) A determination by the independent review organization whether the dispute falls within any of the categories of issues that are eligible for independent review. (c) A determination of the dispute by the independent review organization in favor of the insurer or enrollee. (3) A synopsis may include a statement describing the illness, condition or other object of medical treatment, subject to section (4) of this rule. (4) Synopses must exclude all facts and other matters that identify or may identify an enrollee. The facts and other matters include but are not limited to the name or address of an enrollee, the location of the provider office or other place of treatment, and the disease, condition or other treated matter, the disclosure of which may reveal the identity of the enrollee. Statutory/Other Authority: ORS 731.244 & ORS 743B.256 Statutes/Other Implemented: ORS 743B.256 History: ID 27-2018, minor correction filed 08/22/2018, effective 08/22/2018 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
836-053-1360 External Review Reporting (1) Each independent review organization shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review for the Director of the Department of Consumer and Business Services during a calendar year. (2) Each independent review organization shall submit to the director, by March 31 of each year for the preceding calendar year, a report in the format specified by the director. The report shall include the information required by this section in the aggregate, for each insurer, for Oregon external reviews only. The information to be included in the report as provided in this section is as follows: (a) The total number of requests for external review received during the reporting period; (b) The number of requests for external review for which the independent review organization has made a final decision and, of those requests, the number that uphold the insurer's final adverse determination; (c) The average length of time for final decision by the independent review organization of: (A) Disputes other than expedited disputes; and (B) Expedited disputes. (d) A summary of the types of coverages or cases for which an external review was sought; (e) The number of requests for which the independent review organization decided that it did not have jurisdiction under ORS 743B.252. (f) The number of external review cases that were terminated as the result of a reconsideration by the insurer of the insurer's final adverse determination after the receipt of additional information from the enrollee or the enrollee's designated representative; and (g) Any other information the director requests or requires. Statutory/Other Authority: ORS 731.244, ORS 743B.253 & ORS 743B.256 Statutes/Other Implemented: ORS 743B.253 & ORS 743B.256 History: ID 28-2018, minor correction filed 08/22/2018, effective 08/22/2018 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
836-053-1365 Fees for External Reviews Fees to be imposed by an independent review organization for its external review of disputes shall be as determined in the competitive solicitation process, but shall be as low as is feasible in the request for proposal process. Fees shall be separately established for initial jurisdictional decisions by an independent review organization and for decisions that call for a more extended review. Statutory/Other Authority: ORS 731.244 & ORS 743B.253 Statutes/Other Implemented: ORS 743B.253 History: ID 29-2018, minor correction filed 08/22/2018, effective 08/22/2018 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
836-053-1404 Definitions; Noncontracting Providers; Co-Morbidity Disorders (1) As used in ORS 743A.168 and OAR Chapter 836: (a) “Behavioral health condition” means any mental or substance use disorder covered by diagnostic categories listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), the International Classification of Diseases, 10th Revision (ICD-10), or the International Classification of Diseases, 11th Revision (ICD-11). (b) “Generally accepted standards of care” means; (A) Standards of care and clinical practice guidelines that: (i) Are generally recognized by health care providers practicing in relevant clinical specialties; and (ii) Are based on valid, evidence-based sources; and (B) Products and services that: (i) Address the specific needs of a patient for the purpose of screening for, preventing, diagnosing, managing or treating an illness, injury or condition or symptoms of an illness, injury or condition; (ii) Are clinically appropriate in terms of type, frequency, extent, site and duration; and (iii) Are not primarily for the economic benefit of an insurer or payer or for the convenience of a patient, treating physician or other health care provider. (c) “Valid, evidence-based sources” includes but is not limited to: (A) Peer-reviewed scientific studies and medical literature; (B) Recommendations of nonprofit health care provider professional associations, and; (C) Specialty societies. (2) A non-contracting provider must cooperate with a health insurer's requirements for review of treatment in ORS 743A.168(2) and (3) to the same extent as a contracting provider in order to be eligible for reimbursement. (3) The exception of a disorder in the definition of "behavioral health condition” in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder. Statutory/Other Authority: ORS 731.244 & ORS 743A.168 Statutes/Other Implemented: ORS 743A.168 History: ID 8-2022, amend filed 12/22/2022, effective 01/01/2023 ID 5-2016, f. & cert. ef. 4-26-16 ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16 ID 3-2015, f. & cert. ef. 5-12-15 ID 19-2014(Temp), f. & cert. ef. 11-14-14 thru 5-12-15 ID 3-2013, f. 6-10-13, cert. ef. 6-17-13 ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13 ID 13-2006, f. 7-14-06 cert. ef. 1-1-07
836-053-1407 Prohibited Exclusions (1) An insurer may not deny benefits for a medically necessary treatment or service for a behavioral health condition based solely upon: (a) The enrollee’s interruption of or failure to complete a prior course of treatment; (b) The insurer’s categorical exclusion of such treatment or service when applied to a class of behavioral health conditions; or (c) The fact that a court ordered the enrollee to receive or obtain the treatment or service for a behavioral health condition, unless otherwise allowed by law. (2) Nothing in this section: (a) Requires coverage of a treatment or service that is or may be specifically excluded from coverage under state law. (b) Prohibits an insurer from including a provision in a contract related to the insurer’s general responsibility to pay for any service under the plan such as an exclusion for third party liability. (c) Requires an insurer to pay for services provided to an enrollee by a school or halfway house or received as part of an educational or training program. However, an insurer may be required to provide coverage of treatment or services related to the enrollee’s education that are provided by a provider and that are included in a medically necessary treatment plan. Statutory/Other Authority: ORS 731.244 & ORS 743A.168 Statutes/Other Implemented: ORS 743A.168 History: ID 8-2022, amend filed 12/22/2022, effective 01/01/2023 ID 3-2015, f. & cert. ef. 5-12-15
836-053-1408 Required Disclosures (1) Insurers must provide an enrollee or an enrollee’s authorized representative reasonable access to and copies of all documents, records, and other information relevant to an enrollee’s claim or request for coverage. (2) Insurers must provide the criteria, guidelines, processes, standards and other factors used to conduct medical necessity, utilization or other clinical reviews for behavioral health conditions. This information must be made available free of charge by the insurer to any current or potential enrollee, beneficiary, or contracting provider upon request, within a reasonable time and in a manner that provides reasonable access to the requestor. (3) Compliance with these disclosure requirements is not determinative of compliance with any other provisions of applicable federal or state law. Statutory/Other Authority: ORS 731.244 & ORS 743A.168 Statutes/Other Implemented: ORS 743A.168 History: ID 8-2022, amend filed 12/22/2022, effective 01/01/2023 ID 3-2015, f. & cert. ef. 5-12-15
836-053-1409 Definitions (1) As used in ORS 743B.281 and 743B.282, “provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services in the practice of a profession. (2) As used in ORS 743B.282, for the purpose of an insurer’s procedure for providing an estimate of an enrollee’s costs for a covered out-of-network procedure or service: (a) The “allowable charge” for a covered procedure or service is the estimated amount established under the insurance policy, whether expressed as an “allowable charge,” “allowable expense,” “eligible fee” or other term denoting the amount on which the benefit is calculated. (b) The “billed charge” is the estimated amount charged by a provider for performance of a procedure or service. Statutory/Other Authority: ORS 731.244 & 743B.285 Statutes/Other Implemented: ORS 743B.281 & 743B.282 History: Renumbered from 836-053-1406, ID 5-2016, f. & cert. ef. 4-26-16 ID 16-2008, f. & cert. ef. 9-24-08
836-053-1410 Procedures (1) An insurer must allocate covered procedures or services to the categories established in ORS 743.874(3) and 743.876(3) in a manner that will enable the insurer to provide a reasonable estimate of an enrollee’s share of costs for a procedure or service. An insurer must determine its allocation according to its Oregon block of business at least once every 12 months to ensure that the procedures and services are currently the most common procedures in the categories. (2) When an insurer provides a combined estimate for two or more procedures or services, the insurer must apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. With the estimate provided under this section, he insurer must disclose to the enrollee that the estimate includes the costs of two or more procedures or services. (3) With any estimate, an insurer must disclose whether the estimate applies only to those costs specifically relating to the procedure or service, such as is given in commonly used procedure codes, or applies to an episode of care that includes the procedure or service and its related costs. (4) As required by the director, an insurer must file the following information for the purpose of assessing the effect of the disclosure requirements in ORS 743.874 and 743.876: (a) The number of requests for estimates under ORS 743.874 and 743.876 received by the insurer in a calendar year; and (b) Of the requests in paragraph (a) of this subsection, the number of requests for in-network procedures and services and the number of requests for out-of-network procedures and services. Statutory/Other Authority: ORS 731.244 & 743.893 Statutes/Other Implemented: ORS 743.874, 743.876 & 743.878 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 16-2008, f. & cert. ef. 9-24-08
836-053-1415 Instructions (1) An insurer must make available to enrollees detailed instructions by telephone and Internet for obtaining estimates and benefit information under ORS 743.874 and 743.876. At a minimum, the instructions must: (a) Specify the information needed by the insurer to provide the estimate, including but not limited to information for identifying the procedure or service and the provider; (b) Describe how an enrollee may obtain an estimate and find benefit information for an in-network procedure, and inform the enrollee that an estimate is not required by law to be provided for a procedure or service that is not included in the insurer’s categories; and (c) Provide a general explanation for obtaining an estimate for an out-of-network procedure or service and specify the information needed for the most accurate estimates. (2) The instructions described in section (1) of this rule may include a statement that the accuracy of an estimate may depend on the specificity and accuracy of the information provided by the enrollee. Statutory/Other Authority: ORS 731.244 & 743.893 Statutes/Other Implemented: ORS 743.874 & 743.876 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 16-2008, f. & cert. ef. 9-24-08
836-053-1420 Purpose and statutory authority The purpose of OAR 836-053-1420 to 836-053-1430 is to establish the form and manner for carriers offering individual and group health benefit plans to report on behavioral health benefits. Statutory/Other Authority: Or Laws 2021, ch 629 Statutes/Other Implemented: Or Laws 2021, ch 629 History: ID 1-2022, adopt filed 02/11/2022, effective 02/15/2022
836-053-1425 Definitions for behavioral health benefits reporting As used in these rules: (1) “Behavioral health benefits” means insurance coverage of mental health treatment and services and substance use disorder treatment and services. (2) “Geographic region” means the regions identified as the specific geographic divisions for Oregon’s individual and small group market as required by OAR 836-053-0465. (3) “Incentive payment” means any compensation arrangement, including but not limited to coordination fees, withholds, bonuses, capitation, or any other compensation, to pay a provider or provider group directly or indirectly. (4) “Median maximum allowable reimbursement rate” means the median of all maximum allowable reimbursement rates, minus incentive payments, paid for each billing code for each provider type during a calendar year. (5) “Partial denial” means the denial and non-reimbursement of portions of a medical claim submitted for services or supplies provided to a covered enrollee as specified in the plan documents. (6) “Time-based office visit” means an in-person office or telehealth visit between a health care provider and a patient in specific increments as determined by the relevant CPT billing code. Statutory/Other Authority: Or Laws 2021, ch 629 Statutes/Other Implemented: Or Laws 2021, ch 629 History: ID 1-2022, adopt filed 02/11/2022, effective 02/15/2022
836-053-1500 Purpose; Statutory Authority; Applicability (1) OAR 836-053-1500 to 836-053-1510 are adopted for the purpose of implementing sections 1 to 4, chapter 575, Oregon Laws 2015 and section 7, chapter 26, Oregon Laws 2016. (2) The requirements set forth in OAR 836-053-1500 to 836-053-1510 apply to prominent carriers. Statutory/Other Authority: ORS 731.244; sec 1 - 4, ch 575, OLs 2015, sec 7, ch 26 & OL 2016 Statutes/Other Implemented: Sections 1 & 3, ch. 575, OL 2015, sec 7, ch. 26 & OL 2016 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 13-2015(Temp), f. & cert. ef. 10-20-15 thru 4-8-16
836-053-1510 Prominent Carrier Reporting Requirements (1) Not later than October 1 of each year from 2016 through 2018, each prominent carrier shall submit to the Department of Consumer and Business Services all non-claims based primary care expenditures for the prior calendar year using the approved file layout and format set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. (2) Each prominent carrier shall submit to department all non-claims based total health care expenditures for the prior calendar year using the approved file layout and format set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. (3) Each category included in the approved file format is mutually exclusive; therefore, expenditures shall only be accounted for in one category. (4) All data shall be submitted to the department no later than October 1 of each year that the prominent carrier is required to report under section (1) of this rule. (5) Claims-based primary care and total health care expenditures will be calculated for each prominent carrier by the Oregon Health Authority using data from the All-Payer All-Claims Database. (6) Expenditures for services or activities outside the primary care setting, regardless of a primary care capacity building intent, are not considered primary care expenditures for purposes of this report. Statutory/Other Authority: ORS 731.244, sec. 7, ch. 26, OL 2016 & 2015 OL Ch. 575 Sec. 1 & 3 Statutes/Other Implemented: 2015 OL Ch. 575 Sec. 1 & 3, sec. 7, ch. 26 & OL 2016 History: ID 27-2023, minor correction filed 07/03/2023, effective 07/03/2023 ID 4-2016, f. & cert. ef. 4-8-16 ID 13-2015(Temp), f. & cert. ef. 10-20-15 thru 4-8-16
836-053-1520 Purpose; Statutory Authority; Applicability The requirements set out in OAR 836-053-1520 to 836-053-1530 apply to insurers offering health benefit plans, as defined in ORS 743B.005, that reimburse the costs of services provided by a national primary care medical home payment model, conducted by the Center for Medicare and Medicaid Innovation in accordance with 42 U.S.C. 1315a, that includes performance incentive payments for primary care. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: 2017 Or Law ch 489 §7 History: ID 4-2018, adopt filed 03/09/2018, effective 03/09/2018
836-053-1525 Definitions The following definitions apply to OAR 836-053-1520 to 836-053-1530: (1) “APAC Data Reporting Program” means the all payer all claims data reporting program pursuant to ORS 442.464, 442.466, and 442.993. (2) “APM” means alternative payment methodologies. (3) “Annual supplemental provider level APM Summary report” means a data set composed of total and primary care-related dollars disbursed, by payment arrangement and line of business in the APAC Data Reporting Program pursuant to OAR 409-025-0120(8) and OAR 409-025-0120(9). (4) “Comprehensive Primary Care Plus (CPC+)” means a national primary care medical home payment model, conducted by the Center for Medicare and Medicaid Innovation in accordance with 42 U.S.C. 1315a, that includes performance-based incentive payments for primary care. (5) “Patient-Centered Primary Care Home (PCPCH)” means a health care team or clinic, defined in ORS 414.655, that meets the standards and has been recognized under OAR 409-055-0040. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: Or Law ch 489 §7 History: ID 4-2018, adopt filed 03/09/2018, effective 03/09/2018
836-053-1530 Reporting Requirements (1) No later than September 30 of each year beginning September 30, 2019, an insurer participating in CPC+ shall submit to the Department of Consumer and Business Services the Annual Supplemental Provider Level APM Summary report using the APAC Data Reporting Program for the prior calendar year. (2) No later than September 30 of each year beginning September 30, 2019, an insurer participating in CPC+ shall submit to the Department of Consumer and Business Services a PCPCH APM Reporting Form (PCPCH-APM-1) for the prior calendar year providing the following information: (a) The number of PCPCHs in their network; (b) The number of PCPCHs in their network with an APM in their contract; (c) The number of PCPCHs in their network offered an APM. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: Or Law ch 489 §7 History: ID 4-2018, adopt filed 03/09/2018, effective 03/09/2018