reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.460 - Records of licensee; examination.

(1) Each surplus lines licensee shall keep a full and true record of each surplus lines insurance contract placed on an Oregon home state risk by or through the licensee as required by ORS 744.068, including a copy of the policy, certificate, cover note or other evidence of insurance showing any of the following items that are applicable:
(a) Amount of the insurance and perils insured;
(b) Brief description of the property insured and its location;
(c) Gross premium charged;
(d) Any return premium paid;
(e) Rate of premium charged upon the several items of property;
(f) Effective date of the contract and the terms thereof;
(g) Name and address of the insured;
(h) Name and address of the insurer;
(i) Amount of tax and other sums to be collected from the insured; and
(j) Identity of the producing insurance producer, any confirming correspondence from the insurer or its representative and the application.
(2) The record of each contract shall be kept open at all reasonable times to examination by the Director of the Department of Consumer and Business Services without notice for a period not less than five years following termination of the contract. [1987 c.774 §129; 2001 c.191 §47; 2003 c.364 §43; 2011 c.660 §16]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.465 - Monthly reports; rules.

(1) On or before the end of each month, each surplus lines licensee shall file with the Director of the Department of Consumer and Business Services, as prescribed by the director, a verified report of all surplus lines insurance transacted on Oregon home state risks during the preceding 90 days. The report need not show transacted surplus lines insurance that was reported in an earlier report. The report shall show:
(a) Aggregate gross premiums written;
(b) Aggregate return premiums; and
(c) Amount of aggregate tax.
(2) The director may direct that reports required under subsection (1) of this section be made to the Surplus Line Association of Oregon and that the Surplus Line Association of Oregon file a combined report thereof with the director. The director may also require that reports required under subsection (1) of this section be made electronically but may exempt a licensee from the requirement for good cause shown.
(3) For the purpose of collecting taxes on insurance covering Oregon home state risks when the insurance is placed outside this state, the director may establish by rule requirements for filing reports on surplus lines insurance transacted outside this state on Oregon home state risks. [1987 c.774 §130; 2001 c.191 §48; 2007 c.71 §236; 2011 c.660 §17]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.470 - Premium tax; collection; payment; refund; rules.

(1)(a) The surplus lines licensee shall pay the Director of the Department of Consumer and Business Services a surplus lines premium tax equal to two percent of the gross amount of premiums received on Oregon home state risks as shown in the report required by ORS 735.465.
(b) Notwithstanding ORS 731.820, the surplus lines licensee shall also pay to the director a tax equal to 0.3 percent of the premium or fees charged by the insurer or the insurer’s insurance producer and other intermediaries for the insurance, for the purpose of maintaining the Department of the State Fire Marshal and paying the expenses incident thereto.
(c) The taxes shall be collected by the surplus lines licensee as specified by the director, in addition to the gross amount of premiums charged by the insurer or the insurer’s insurance producer and other intermediaries for the insurance. The taxes on any portion of the premium unearned at termination of insurance having been credited by the state to the licensee shall be returned to the policyholder directly by the surplus lines licensee or through the producing insurance producer, if any. The surplus lines licensee is prohibited from absorbing the taxes, and from rebating for any reason, any part of the taxes.
(2) The surplus lines taxes are due quarterly on the 45th day following the calendar quarter in which the premium is collected. The taxes shall be paid to and reported on forms prescribed by the director or upon the director’s order paid to and reported on forms prescribed by the Surplus Line Association of Oregon.
(3) Notwithstanding subsection (2) of this section, if a surplus lines license is terminated or nonrenewed for any reason, the taxes described in this section are due on the 30th day after the termination or nonrenewal.
(4) For the purposes of carrying out the Nonadmitted and Reinsurance Reform Act of 2010 (P.L. 111-203, Title V, Subtitle B), the director may collect taxes on 100 percent of the gross amount of premiums on Oregon home state risks. If the director enters into a compact or otherwise establishes procedures with other states pursuant to ORS 735.418, the director by rule shall establish procedures to facilitate the reporting, collection, payment, allocation and disbursement of premium taxes on Oregon home state risks that also include risks allocable to other states.
(5) As used in this section, "gross amount of premiums" has the meaning given that term in ORS 731.808. [1987 c.774 §131; 1989 c.288 §2; 1995 c.786 §10; 2001 c.191 §48a; 2003 c.364 §44; 2007 c.71 §237; 2011 c.660 §8; 2021 c.539 §145]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.475 - Suit to recover unpaid tax.

If the tax collectible by a surplus lines licensee under ORS 735.400 to 735.495 is not paid within the time prescribed, the same shall be recoverable in a suit brought by the Director of the Department of Consumer and Business Services against the surplus lines licensee. [1987 c.774 §132; 1989 c.288 §3; 2001 c.191 §48b]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.480 - Suspension or revocation of license; refusal to renew; grounds.

The Director of the Department of Consumer and Business Services may suspend, revoke or refuse to renew the license of a surplus lines licensee after notice and hearing as provided under the applicable provision of this state’s laws upon any one or more of the following grounds:
(1) Removal of the surplus lines licensee’s office from this state, if the licensee is a resident insurance producer;
(2) Removal of the surplus lines licensee’s office accounts and records from the principal place of business of the licensee under ORS 744.068 during the period during which such accounts and records are required to be maintained under ORS 735.460;
(3) Closing of the surplus lines licensee’s office for a period of more than 30 business days, unless permission is granted by the director;
(4) Failure to make and file required reports;
(5) Failure to transmit required tax on surplus lines premiums;
(6) Violation of any provision of ORS 735.400 to 735.495; or
(7) For any cause for which an insurance license could be denied, revoked, suspended or renewal refused under ORS 744.074. [1987 c.774 §133; 1989 c.288 §4; 2001 c.191 §49; 2003 c.364 §45]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.485 - Actions against surplus lines insurer.

(1) A surplus lines insurer may be sued upon any cause of action arising in this state under any surplus lines insurance contract on an Oregon home state risk made by it or evidence of insurance issued or delivered by the surplus lines licensee pursuant to the procedure provided in ORS 735.490. Any surplus lines policy issued by the surplus lines licensee shall contain a provision stating the substance of this section and designating the person to whom process shall be delivered.
(2) Each surplus lines insurer assuming surplus lines insurance shall be considered thereby to have subjected itself to ORS 735.400 to 735.495.
(3) The remedies provided in this section are in addition to any other methods provided by law for service of process upon insurers.
(4) When a nonresident surplus lines insurance producer transacts outside this state a surplus lines insurance contract covering an Oregon home state risk, the producer and the surplus lines insurer of the contract are subject to this section and to ORS 735.490 or to rules adopted by the director in lieu thereof. [1987 c.774 §134; 1989 c.288 §5; 2001 c.191 §49a; 2011 c.660 §18]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.490 - Jurisdiction in action against insurer; service of summons and complaint; response.

(1) An insurer transacting insurance on an Oregon home state risk under the provisions of ORS 735.400 to 735.495 may be sued upon any cause of action, arising under any policy of insurance so issued and delivered by it, in the courts for the county where the insurance producer who registered or delivered the policy resides or transacts business, by the service of summons and complaint made upon the insurance producer for the insurer.
(2) Any insurance producer served with summons and complaint in any such cause shall forthwith mail the summons and complaint, or a true and complete copy thereof, by registered or certified mail with proper postage affixed and properly addressed, to the insurer being sued.
(3) The insurer shall have 40 days from the date of the service of the summons and complaint upon the insurance producer in which to plead, answer or defend any such cause.
(4) Upon service of summons and complaint upon the insurance producer for the insurer, the court in which the action is begun shall be deemed to have duly acquired personal jurisdiction of the defendant insurer so served.
(5) An insurer and policyholder may agree to waive the provisions of subsections (1) to (4) of this section governing service and venue with respect to a surplus lines insurance contract for commercial property and casualty risk if the waiver is specifically referred to in the contract or in an indorsement attached to the contract. [1987 c.774 §137; 2001 c.191 §49b; 2003 c.364 §46; 2011 c.660 §19]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.495 - Short title; severability.

(1) ORS 735.400 to 735.495 shall be known and may be cited as "The Oregon Surplus Lines Law."
(2) If any provisions of ORS 735.400 to 735.495, or the application of such provision to any person or circumstance, is held invalid, the remainder of ORS 735.400 to 735.495 and the application of such provision to persons or circumstances other than those as to which it is held invalid, shall not be affected. [1987 c.774 §§116,136]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.510 - Notice to department of specified changes to practice.

A certified retainer medical practice shall:
(1) Notify the Department of Consumer and Business Services immediately whenever:
(a) The license of a provider who has provided services on behalf of the practice is denied, suspended, revoked or not renewed in this state or in any other jurisdiction; or
(b) The authority of the practice to operate in another jurisdiction is denied, suspended, revoked or not renewed.
(2) Notify the department no later than 30 days after any change to the name, address or contact information that is provided in the application for certification under ORS 735.500. [2011 c.499 §3]
Note:
See note under 735.500.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.515 - Charges for services not covered by contract.

(1) As used in this section:
(a) "Dental services contract" means a contract between an insurer and a provider or a group of providers to provide dental health services for enrollees. "Dental services contract" does not include a contract of employment or a contract creating legal entities and ownership thereof that are authorized under ORS chapter 58, 60 or 70, or other similar professional organizations permitted by statute.
(b) "Enrollee" means a person entitled to receive dental health benefits from an insurer.
(c) "Provider" means a person licensed or otherwise authorized by the laws of this state to administer dental health services in the ordinary course of business or practice of a profession.
(2) A dental services contract may not restrict the price that a provider may charge for services provided to an enrollee unless the services are covered by the insurer. [2010 c.74 §2]
Note:
735.515 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 735 or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.520 - Oregon Essential Workforce Health Care Program; supplemental payments to eligible employers; requirements for participation; rules.

(1) As used in this section:
(a) "Eligible employer" means an operator of a facility that:
(A) Is a participating provider in the state medical assistance program;
(B) Elects to participate in the Oregon Essential Workforce Health Care Program; and
(C) Meets other requirements prescribed by the Oregon Health Authority by rule.
(b) "Facility" includes:
(A) A long term care facility licensed under ORS 441.020;
(B) A residential facility as defined in ORS 443.400; and
(C) An in-home care agency licensed under ORS 443.315.
(2) The Oregon Essential Workforce Health Care Program is established in the Oregon Health Authority. The authority, in coordination with the Department of Human Services, shall provide supplemental payments, as approved by the Centers for Medicare and Medicaid Services, to eligible employers to be used by the eligible employers to provide health care benefits to the employees of their facilities.
(3) To participate in the program, an eligible employer shall:
(a) Enter into a memorandum of understanding with the authority that specifies how the supplemental payments will be used;
(b) Agree to participate in evidence-based workforce and quality of care improvements; and
(c) Annually report quality and other metrics.
(4) The authority, in coordination with the department, may adopt rules to carry out the provisions of this section. [2021 c.595 §1]
Note:
735.520 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 735 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.532 - Registration of pharmacy benefit managers; fees; rules.

(1) To conduct business in this state, a pharmacy benefit manager must register with the Department of Consumer and Business Services and annually renew the registration.
(2) To register under this section, a pharmacy benefit manager must:
(a) Submit an application to the department on a form prescribed by the department by rule.
(b) Pay a registration fee in an amount adopted by the department by rule.
(3) To renew a registration under this section, a pharmacy benefit manager must pay a renewal fee in an amount adopted by the department by rule.
(4) The department shall deposit all moneys collected under this section into the Consumer and Business Services Fund created in ORS 705.145.
(5) Any fee adopted by the department under this section must be based on the department’s reasonable costs in administering ORS 735.530 to 735.552. [2013 c.570 §3; 2017 c.73 §3]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.533 - Denial, suspension or revocation of registration as pharmacy benefit manager; basis; complaint; rules.

(1) In accordance with ORS chapter 183, the Department of Consumer and Business Services may deny an application for registration as a pharmacy benefit manager or an application for renewal of a registration as a pharmacy benefit manager, and may suspend or revoke a registration as a pharmacy benefit manager, if the department finds that an applicant or registrant:
(a) Falsified an application for registration or for the renewal of a registration or engaged in any dishonest act in relation to the application;
(b) Engaged in dishonesty, fraud or gross negligence in the conduct of business as a pharmacy benefit manager;
(c) Engaged in conduct that resulted in a conviction of a felony under the laws of any state or of the United States, to the extent that such conduct may be considered under ORS 670.280;
(d) Was convicted under the laws of any state or of the United States of any crime of which an essential element is dishonesty or fraud;
(e) Had a certificate of authority or authority to conduct business as a pharmacy benefit manager denied, revoked or suspended in another state;
(f) Failed to pay a civil penalty imposed by final order of the department or to comply with the terms of suspension set by the department;
(g) Failed to meet the terms of a consent decree approved by a court of competent jurisdiction in this state, or a consent order made between the department and the pharmacy benefit manager;
(h) Refused to be examined or to produce accounts, records or files for examination, including the refusal by any officer of the applicant or registrant to give information with respect to the affairs of the pharmacy benefit manager, or refused to perform any other legal obligation with respect to an examination by the department; or
(i) Violated any rule or order of the department or any provision of the Insurance Code.
(2) The department may prescribe by rule a procedure by which a pharmacy or an entity acting on behalf of a pharmacy may file a complaint with the department alleging that a pharmacy benefit manager has engaged in conduct described in this section. The department may restrict the right of a pharmacy or entity to file a complaint only to the extent necessary to prevent abuse of the complaint process. [2017 c.73 §2]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.536 - Requirements for pharmacy benefit manager’s reimbursement for cost of drugs; rules.

(1) As used in this section, "out-of-pocket cost" means the amount paid by an enrollee under the enrollee’s coverage, including deductibles, copayments, coinsurance or other expenses as prescribed by the Department of Consumer and Business Services by rule.
(2) A pharmacy benefit manager registered under ORS 735.532:
(a) May not require a prescription to be filled or refilled by a mail order pharmacy as a condition for reimbursing the cost of the drug.
(b) Except as provided in paragraph (c) of this subsection, may require a prescription for a specialty drug to be filled or refilled at a specialty pharmacy as a condition for the reimbursement of the cost of a drug.
(c) Shall reimburse the cost of a specialty drug that is filled or refilled at a network pharmacy that is a long term care pharmacy.
(d)(A) Shall allow a network pharmacy to mail, ship or deliver prescription drugs to its patients as an ancillary service.
(B) Is not required to reimburse a delivery fee charged by a pharmacy for a delivery described in subparagraph (A) of this paragraph unless the fee is specified in the contract between the pharmacy benefit manager and the pharmacy.
(e) May not require a patient signature as proof of delivery of a mailed or shipped prescription drug if the network pharmacy:
(A)(i) Maintains a mailing or shipping log signed by a representative of the pharmacy; or
(ii) Maintains each notification of delivery provided by the United States Postal Service or a package delivery service; and
(B) Is responsible for the cost of mailing, shipping or delivering a replacement for a drug that was mailed or shipped but not received by the enrollee.
(f) May not penalize a network pharmacy for or otherwise directly or indirectly prevent a network pharmacy from informing an enrollee of the difference between the out-of-pocket cost to the enrollee to purchase a prescription drug using the enrollee’s pharmacy benefit and the pharmacy’s usual and customary charge for the prescription drug.
(3) The Department of Consumer and Business Services may adopt rules to carry out the provisions of this section. [2019 c.526 §2]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.537 - Reports to department regarding payments received from manufacturers and disposition of payments from manufacturers.

(1) As used in this section:
(a) "Carrier" has the meaning given that term in ORS 743B.005.
(b) "Manufacturer" has the meaning given that term in ORS 646A.689.
(c) "Prescription drug" has the meaning given that term in ORS 646A.689.
(2) Not later than June 1 of each calendar year, a pharmacy benefit manager registered under ORS 735.532 shall file a report with the Department of Consumer and Business Services. The report must contain, for the immediately preceding calendar year, the aggregated dollar amount of rebates, fees, price protection payments and any other payments the pharmacy benefit manager received from manufacturers:
(a) Related to managing the pharmacy benefits for carriers issuing health benefit plans in this state; and
(b) That were:
(A) Passed on to carriers issuing health benefit plans in this state or enrollees at the point of sale of a prescription drug in this state; or
(B) Retained as revenue by the pharmacy benefit manager.
(3) The report described in subsection (2) of this section may not disclose:
(a) The identity of a carrier or an enrollee;
(b) The price charged for a specific prescription drug or class of drugs; or
(c) The amount of any rebate or fee provided for a specific prescription drug or class of prescription drugs.
(4) Information submitted to the department under this section is confidential and not subject to disclosure except as provided in subsection (5) of this section and ORS 705.137.
(5) Not later than October 1 of each calendar year, the department shall publish on the department’s website the aggregated data from all reports filed by pharmacy benefit managers under this section for the preceding calendar year. The department shall publish the data in a manner that does not disclose confidential information of pharmacy benefit managers. [2023 c.466 §2]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.540 - Definitions for ORS 735.540 to 735.552.

As used in ORS 735.540 to 735.552:
(1) "Audit" means an on-site or remote review of the records of a pharmacy by or on behalf of an entity.
(2) "Clerical error" means a minor error:
(a) In the keeping, recording or transcribing of records or documents or in the handling of electronic or hard copies of correspondence;
(b) That does not result in financial harm to an entity; and
(c) That does not involve dispensing an incorrect dose, amount or type of medication or dispensing a prescription drug to the wrong person.
(3) "Entity" includes:
(a) A pharmacy benefit manager;
(b) An insurer;
(c) A third party administrator;
(d) A state agency; or
(e) A person that represents or is employed by one of the entities described in this subsection.
(4) "Fraud" means knowingly and willfully executing or attempting to execute a scheme, in connection with the delivery of or payment for health care benefits, items or services, that uses false or misleading pretenses, representations or promises to obtain any money or property owned by or under the custody or control of any person. [2013 c.570 §4]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.542 - Pharmacy claims audits; requirements.

An entity that audits claims or an independent third party that contracts with an entity to audit claims:
(1) Must establish, in writing, a procedure for a pharmacy to appeal the entity’s findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy’s claims;
(2) May not conduct an audit of a claim more than 24 months after the date the claim was adjudicated by the entity;
(3) Must give at least 15 days’ advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;
(4) May not conduct an on-site audit during the first five days of any month without the pharmacy’s consent;
(5) Must conduct the audit in consultation with a pharmacist who is licensed by this or another state if the audit involves clinical or professional judgment;
(6) May not conduct an on-site audit of more than 250 unique prescriptions of a pharmacy in any 12-month period except in cases of alleged fraud;
(7) May not conduct more than one on-site audit of a pharmacy in any 12-month period;
(8) Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;
(9) Must pay any outstanding claims of a pharmacy no more than 45 days after the earlier of the date all appeals are concluded or the date a final report is issued under ORS 735.550 (3);
(10) May not include dispensing fees or interest in the amount of any overpayment assessed on a claim unless the overpaid claim was for a prescription that was not filled correctly;
(11) May not recoup costs associated with:
(a) Clerical errors; or
(b) Other errors that do not result in financial harm to the entity or a consumer; and
(12) May not charge a pharmacy for a denied or disputed claim until the audit and the appeals procedure established under subsection (1) of this section are final. [2013 c.570 §5]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.544 - Pharmacy claims audits; standards for review of claims.

An entity’s finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions or refills for similar drugs. [2013 c.570 §6]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.546 - Pharmacy claims audits; auditors.

An entity that contracts with an independent third party to conduct audits may not:
(1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or
(2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject to the audit or the holder of the policy or certificate of insurance that paid the claim. [2013 c.570 §7]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.548 - Pharmacy claims audits; validation of claims.

For purposes of ORS 735.540 to 735.552, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim:
(1) An electronic or physical copy of a prescription that complies with ORS chapter 689 if the prescribed drug was, within 14 days of the dispensing date:
(a) Picked up by the patient or the patient’s designee;
(b) Delivered by the pharmacy to the patient; or
(c) Sent by the pharmacy to the patient using the United States Postal Service or other common carrier;
(2) Point of sale electronic register data showing purchase of the prescribed drug, medical supply or service by the patient or the patient’s designee; or
(3) Electronic records, including electronic beneficiary signature logs, electronically scanned and stored patient records maintained at or accessible to the audited pharmacy’s central operations and any other reasonably clear and accurate electronic documentation that corresponds to a claim. [2013 c.570 §8]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.550 - Pharmacy claims audits; reports of findings; opportunity to resubmit claim and to contest finding.

(1)(a) After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than 45 days after the date on which the audit was completed and must be sent:
(A) By mail or common carrier with a return receipt requested; or
(B) Electronically with electronic receipt confirmation.
(b) An entity shall provide a pharmacy receiving a preliminary report under this subsection no fewer than 45 days after receiving the report to contest the report or any findings in the report in accordance with the appeals procedure established under ORS 735.542 (1) and to provide additional documentation in support of the claim. The entity shall consider a reasonable request for an extension of time to submit documentation to contest the report or any findings in the report.
(2) If an audit results in the dispute or denial of a claim, the entity conducting the audit shall allow the pharmacy to resubmit the claim using any commercially reasonable method, including facsimile, mail or electronic mail.
(3) An entity must provide a pharmacy that is the subject of an audit with a final report of the audit no later than 60 days after the later of the date the preliminary report was received or the date the pharmacy contested the report using the appeals procedure established under ORS 735.542 (1). The final report must include a final accounting of all moneys to be recovered by the entity.
(4) Recoupment of disputed funds from a pharmacy by an entity or repayment of funds to an entity by a pharmacy, unless otherwise agreed to by the entity and the pharmacy, shall occur after the audit and the appeals procedure established under ORS 735.542 (1) are final. If the identified discrepancy for an individual audit exceeds $40,000, any future payments to the pharmacy may be withheld by the entity until the audit and the appeals procedure established under ORS 735.542 (1) are final. [2013 c.570 §9]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.552 - Pharmacy claims audits; exception for fraud.

ORS 735.540 to 735.552 do not:
(1) Preclude an entity from instituting an action for fraud against a pharmacy;
(2) Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is evidenced by physical review, review of claims data or statements or other investigative methods; or
(3) Apply to a state agency that is conducting audits or a person that has contracted with a state agency to conduct audits of pharmacy records for prescription drugs paid for by the state medical assistance program. [2013 c.570 §10]
Note:
See note under 735.530.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.632 - License requirement for conducting business as discount medical plan organization.

(1) A person may not conduct business as or purport to conduct business as a discount medical plan organization unless the person first obtains a license to operate as a discount medical plan organization from the Director of the Department of Consumer and Business Services in accordance with ORS 735.634.
(2) The license requirement set forth in subsection (1) of this section does not apply to an insurer that offers a discount medical plan. [Formerly 742.422]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.633 - Requirement for contract with provider; contents of contract; retention of record.

(1) A discount medical plan organization shall have a written contract or other written agreement with all providers or provider networks that the organization includes or purports to include in a discount medical plan, or with an entity that contracts with or enters into an agreement with a provider network on the organization’s behalf.
(2) The contract or other agreement between a discount medical plan organization and a provider must include:
(a) A list of the medical and ancillary services included in the discount medical plan;
(b) The provider’s discount rate or rates or a schedule that reflects the provider’s fixed or discounted prices for the medical and ancillary services subject to the discount medical plan; and
(c) A provision in which the provider agrees not to charge plan members more for medical and ancillary services than the amount listed in the provider’s price schedule or an amount that reflects the application of the provider’s discount rate.
(3) The contract or other agreement between a discount medical plan organization and a provider network, or between an entity and a provider network when the entity contracts with or enters into an agreement with a provider network on the organization’s behalf, shall require the provider network to have written agreements with providers that, in addition to meeting the requirements of subsection (2) of this section:
(a) Authorize the provider network to contract with or enter into an agreement with the discount medical plan organization or the entity on behalf of the provider; and
(b) Require the provider network to maintain an up-to-date list of the providers that are part of the provider network and to provide the updated list each month to the discount medical plan organization.
(4) A discount medical plan organization shall retain copies of the contracts or agreements and other documents described in this section at all times during which the organization operates in this state. [Formerly 742.424]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.636 - Duties of licensee.

A licensee shall:
(1) Notify the Director of the Department of Consumer and Business Services immediately whenever the licensee’s license or other form of authority to operate as a discount medical plan organization in another jurisdiction is suspended, revoked or not renewed in that jurisdiction.
(2) Describe in a notice to the director any change in the name, address or contact information of the discount medical plan organization provided in the application under ORS 735.634 within 30 days after making the change. [Formerly 742.428]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.637 - License term; renewal; rules.

A license obtained under ORS 735.634 is effective for one year, or for a longer period if the Director of the Department of Consumer and Business Services so prescribes by rule. The director shall prescribe by rule conditions and procedures under which a licensee may renew a license that has expired. [Formerly 742.430]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.638 - Duties of discount medical plan organization.

A discount medical plan organization shall establish or provide, in connection with every discount medical plan:
(1) A 30-day period in which new plan members may review the discount medical plan and decide whether to continue or to cancel the plan for any reason. The discount medical plan organization shall provide to a member who cancels a discount medical plan within the 30-day period a full and unconditional refund for any fees, service or subscription charges, dues or other consideration the member paid, except that the discount medical plan organization may retain the amount of any one-time processing fee that is less than an amount established by the Director of the Department of Consumer and Business Services by rule. The 30-day period begins on the day following the date on which the member completed any application for the plan or the day following the date on which the member paid any fees, service or subscription charges, dues or other consideration, whichever is later.
(2) A standard set of procedures by which a new plan member may obtain a refund under subsection (1) of this section.
(3) A toll-free telephone line and an Internet website. The toll-free telephone line must enable plan members to contact the discount medical plan organization with questions and requests for assistance. The website must list all providers in the organization’s provider network, and the organization must provide the same information to plan members in writing upon request.
(4) Disclosures, in writing in a font not less than 12 points in size and on the first content page of advertisements, marketing materials or brochures made available to the public and relating to a discount medical plan, that:
(a) The discount medical plan is not insurance; and
(b) Plan members must pay for all medical and ancillary services, but will receive a discount from providers. [Formerly 742.432]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.639 - Prohibited activities.

(1) A person may not use or disseminate in marketing, advertising, promotional, sales or plan documents or other informational materials for discount medical plans or in communications with plan members or prospective plan members:
(a) Misleading, deceptive or false statements; or
(b) The terms "health plan," "coverage," "copay," "copayments," "deductible," "preexisting condition," "guaranteed issue," "premium," "preferred provider organization" or other terms in a manner that could reasonably mislead an individual into believing that the discount medical plan is insurance.
(2) For the purposes of subsection (1) of this section, "misleading, deceptive or false statements" includes, but is not limited to, statements that:
(a) Are misleading in fact or implication, including statements that, while containing truthful elements, conceal or omit information necessary or relevant for a consumer to make informed decisions concerning discount medical plans; or
(b) Have a capacity or tendency to mislead or deceive based on the overall impression a reasonable consumer may form after seeing or hearing the statements.
(3) A person may not represent in any marketing, advertising, promotional, sales or plan documents or other informational materials for a discount medical plan or in communications with plan members or prospective plan members that the State of Oregon reviews or approves the discount medical plan.
(4) Before a person uses an advertisement, a brochure, a discount card or promotional or marketing material for marketing, promoting, selling or distributing a discount medical plan, the discount medical plan organization shall approve the material in writing.
(5) At the request of the Director of the Department of Consumer and Business Services, a discount medical plan organization shall submit to the director an advertisement, a brochure, a discount card or promotional or marketing material used for marketing, promoting, selling or distributing a discount medical plan. [Formerly 742.434]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.641 - Investigative powers of director; expenses.

The Director of the Department of Consumer and Business Services may investigate a person operating or purporting to operate as a discount medical plan organization and may require the person at any time to produce marketing, promotional and advertising materials, records, books, files or other information the person uses in conducting business as a discount medical plan organization. During an investigation, the person shall respond to the director’s inquiries promptly and truthfully and in the manner or form the director requires. The person subject to an investigation under this section shall pay the expenses incurred in conducting the investigation. [Formerly 742.436]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.642 - License suspension, revocation or failure to renew; grounds; effect.

(1) The Director of the Department of Consumer and Business Services by order may suspend, revoke or refuse to renew a license issued under ORS 735.634 if the director finds in writing that:
(a) Any fact or condition exists that, if the fact or condition had existed at the time the licensee applied for a license to operate as a discount medical plan organization, would have been grounds for the director to deny a license to the licensee;
(b) The licensee has not complied or is not complying with the licensee’s obligations under ORS 735.633, 735.634, 735.636, 735.638 or 735.641 or any rule adopted thereunder or the licensee has violated or is violating a prohibition under ORS 735.639; or
(c) The licensee’s license or other authority to operate as a discount medical plan organization in another state has been suspended or revoked or has not been renewed.
(2) A licensee subject to an order of the director suspending or revoking a license shall have an opportunity for a hearing under ORS 183.413 to 183.470.
(3) After the director issues a final order to suspend or revoke a license, the person subject to the order may not conduct further business as a discount medical plan organization in this state. Immediately after the director issues a final order suspending or revoking a license, the person subject to the order shall:
(a) Cease operations as a discount medical plan organization in this state;
(b) Cancel all pending transactions with plan members and refund any fees, service or subscription charges, dues or other consideration collected in exchange for services the person would have provided to plan members in connection with a discount medical plan after the effective date of the final order suspending or revoking the person’s license; and
(c) Wind up all business conducted in connection with the person’s operations as a discount medical plan organization in this state, if necessary. [Formerly 742.438]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.643 - Injunction; damages; venue; time for commencing action.

(1) A person, a municipal or other public corporation or, at the request of the Director of the Department of Consumer and Business Services, the Attorney General may bring an action in a circuit court of this state against a person that operates or purports to operate as a discount medical plan organization but that has not obtained a license under ORS 735.634, to:
(a) Enjoin the person from operating or purporting to operate as a discount medical plan organization or from violating ORS 735.638 or 735.639 or any rule adopted thereunder; or
(b) Recover actual damages or statutory damages under this section that arise from the person’s violation of ORS 735.638 or 735.639 or any rule adopted thereunder.
(2) A plaintiff may bring an action under this section in the county where:
(a) The plaintiff resides or conducts business; or
(b) The defendant marketed, offered for sale or sold, promoted, distributed or advertised a discount medical plan.
(3) If the court finds that the defendant has violated ORS 735.632, 735.638 or 735.639 or any rule adopted thereunder, the court shall enjoin the defendant from continuing the violation.
(4) Unless a plaintiff seeks actual or statutory damages under this section, the plaintiff need not allege or prove actual damages to bring an action for an injunction under this section.
(5) In addition to injunctive relief, the plaintiff who prevails in an action brought under this section is entitled to recover from the defendant:
(a) $100 for each discount medical plan membership sold or otherwise distributed within this state or $10,000, whichever is greater;
(b) Three times the amount of actual damages, if any, that the plaintiff sustained;
(c) Reasonable attorney fees;
(d) Costs; and
(e) Any other relief the court deems proper.
(6) A plaintiff must commence an action under this section within two years after the date on which the violation described in subsection (1) of this section occurred or within two years after the plaintiff bringing the action discovered or in the exercise of reasonable diligence should have discovered the violation. The plaintiff may have an additional 180 days after the two-year period provided in this subsection within which to commence an action if the plaintiff can prove by a preponderance of the evidence that the plaintiff failed to timely commence the action because of conduct by the defendant calculated solely to induce the plaintiff to refrain from or postpone commencement of the action.
(7) The remedies provided in this section are cumulative and are in addition to any other applicable criminal, civil or administrative penalties. [Formerly 742.440]
Note:
See note under 735.631.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.720

[Formerly 653.800; 2003 c.684 §8; 2005 c.727 §§5,5a; 2005 c.744 §§23d,23e,23g; 2007 c.70 §317; renumbered 414.841 in 2009]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.722

[Formerly 653.805; 2003 c.128 §1; 2003 c.683 §4; 2003 c.784 §12; 2005 c.238 §6; 2005 c.262 §6; 2005 c.727 §6; 2005 c.744 §24a; 2009 c.595 §1125; renumbered 414.842 in 2009]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 735 - Alternative Insurance › Section 735.724

[Formerly 653.810; 2003 c.128 §2; 2003 c.683 §1; 2005 c.238 §7; 2005 c.262 §7; 2005 c.727 §7; 2005 c.744 §25; renumbered 414.844 in 2009]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 737 - Rates and Rating Organizations › Section 737.007 - "Rating organization" defined.

(1) As used in this chapter, unless the context requires otherwise, "rating organization" means:
(a) Every person, other than an insurer, whether located within or outside this state who has as the person’s object or purpose the making of rates, rating plans or rating systems; or
(b) Two or more insurers which act in concert for the purpose of making rates, rating plans or rating systems.
(2) Subsection (1) of this section does not include, apply to or affect two or more insurers operating within the specific authorizations contained in ORS 737.275, 737.312, 737.365, 737.390 and 737.526. [1969 c.690 §14]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 737 - Rates and Rating Organizations › Section 737.012 - "Advisory organization" defined.

As used in this chapter, unless the context requires otherwise, "advisory organization" means every group, association or other organization of insurers, whether located within or outside this state, which assists authorized insurers which make their own filings or licensed rating organizations in rate making, by the collection and furnishing of loss or expense statistics or by the submission of recommendations, but which does not make filings under this chapter. [1969 c.690 §15]