reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.284 - Alternative mechanism for disclosure of costs and charges.

The Director of the Department of Consumer and Business Services may waive the requirements of ORS 743B.281 or 743B.282 to allow an insurer to use an alternative disclosure mechanism, provided that the mechanism enables enrollees to access information substantially similar to or more extensive than the information disclosed in ORS 743B.281 or 743B.282. [Formerly 743.883]
Note:
See note under 743B.280.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.285 - Rules.

The Director of the Department of Consumer and Business Services shall adopt rules necessary to carry out the purposes of ORS 743B.280 to 743B.285. [Formerly 743.893]
Note:
See note under 743B.280.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.288 - Balance billing prohibited for labor and delivery services rendered by out-of-network provider to which insured was diverted during public health emergency.

(1) As used in this section:
(a) "In-network provider" means an individual or facility that contracts with a health benefit plan or health care service contractor to provide health care services to an individual insured under the health benefit plan or health care service contract.
(b) "Out-of-network provider" means an individual or facility that does not contract with a health benefit plan or health care service contractor to provide health care services to an individual insured under the health benefit plan or health care service contract.
(2) An out-of-network provider that is licensed or certified in this state may not bill an individual insured under a health benefit plan or a health care service contract for the costs of labor or delivery services provided by the out-of-network provider if the services are provided by the out-of-network provider due solely to the diversion of the individual from an in-network provider during a state or federally declared public health emergency.
(3) Subsection (2) of this section does not prohibit any provider from billing an individual insured under a health benefit plan or health care service contract for coinsurance, copayments or deductibles applicable to labor and delivery services provided by in-network providers under the terms of the health benefit plan or health care service contract. [2022 c.72 §4]
Note:
743B.288 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743B 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 743B - Health Benefit Plans: Individual and Group › Section 743B.290 - Hospital payment of copayment or deductible for insured patient.

An insurer offering a policy or certificate of health insurance may not prohibit a hospital, as a condition of reimbursing a claim for hospital services, from paying or waiving all or a portion of a copayment or deductible owed by an insured under the policy or certificate. [2019 c.497 §9]
Note:
743B.290 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.300 - Disclosure of differences in replacement health insurance policies; nonduplication for persons 65 and older; rules.

(1) The Director of the Department of Consumer and Business Services shall adopt by rule requirements for disclosure by group and individual health insurers to individual and group health insurance policyholders the difference between coverage under the existing policy and coverage being offered to replace that coverage.
(2) The provisions of this section do not apply to disability income insurance.
(3) The director shall adopt by rule requirements for nonduplication and replacement of major medical, Medicare supplement, long term care and special illness policies for applicants 65 years of age and older. The insurance producer shall offer to compare for any applicants 65 years of age and older the applicant’s existing policy or policies and coverage being offered to replace or supplement the applicant’s existing coverage. [Formerly 743.013]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.310 - Rescinding coverage; permissible bases; notice; rules.

(1) As used in this section, "rescind" means to retroactively cancel or discontinue coverage under a health benefit plan or group or individual health insurance policy for reasons other than failure to timely pay required premiums or required contributions toward the cost of coverage.
(2) An insurer may not rescind coverage of an individual under a health benefit plan or group or individual health insurance policy unless:
(a) The individual or a person seeking coverage on behalf of the individual:
(A) Performs an act, practice or omission that constitutes fraud; or
(B) Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan or policy; and
(b) The insurer provides at least 30 days’ advance written notice, in the form and manner prescribed by the Department of Consumer and Business Services, to the individual.
(3) An insurer may not rescind coverage of a group under a health benefit plan unless:
(a) The plan sponsor:
(A) Performs an act, practice or omission that constitutes fraud; or
(B) Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan; and
(b) The insurer provides at least 30 days’ advance written notice, in the form and manner prescribed by the department, to each plan enrollee or policy holder who would be affected by the rescission of coverage.
(4) An insurer that rescinds a plan or policy must provide notice of the rescission to the department in the form, manner and time frame prescribed by the department by rule.
(5) This section does not apply to long term care insurance that is subject to ORS 743.650 to 743.665. [Formerly 743.894]
Note:
743B.310 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.320 - Minimum grace period; notice upon termination of policy; effect of failure to notify.

(1) A group health insurance policy shall contain a provision allowing a minimum grace period of 10 days after the premium due date for payment of premium.
(2) An insurer of a group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, that seeks to terminate a policy for nonpayment of premium shall notify the policyholder as described in ORS 743B.323.
(3) An insurer of a group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall notify the group policyholder when the policy is terminated and the coverage is not replaced by the group policyholder. The notice required under this subsection:
(a) Must be given on a form prescribed by the Department of Consumer and Business Services;
(b) Must explain the rights of the certificate holders regarding continuation of coverage provided by federal and state law; and
(c) Must be given by mail and must be mailed not later than 10 working days after the date on which the group policy terminates according to the terms of the policy.
(4) A group health insurance policy to which subsection (3) of this section applies shall contain a provision requiring the insurer to notify the group policyholder when the policy is terminated and the coverage is not replaced by the group policyholder. Each certificate issued under the policy shall also contain a statement of the provision required under this subsection.
(5) If an insurer fails to give notice as required by this section, the insurer shall continue the group health insurance policy of the group policyholder in full force from the date notice should have been provided until the date that the notice is received by the policyholder and shall waive the premiums owing for the period for which the coverage is continued under this subsection. The time period within which the certificate holder may exercise any right to continuation shall commence on the date that the policyholder receives the notice.
(6) The insurer shall supply the employer holding the terminated policy with the necessary information for the employer to be able to notify properly the employee of the employee’s right to continuation of coverage under state and federal law. [Formerly 743.560]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.323 - Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium; rules.

(1) Before a health insurer selling an individual policy or group health benefit plan may cancel a policy for nonpayment of premium, the insurer must mail a separate notice to the policyholder informing the policyholder that the premium was not received and that the policy will be terminated as of the premium due date if the premium is not received by the end of the applicable grace period required by ORS 743.417 and 743B.320.
(2) The notice described in subsection (1) of this section shall be in writing and mailed by first class mail to the last-known address of the policyholder at least:
(a) Ten days prior to the end of the grace period specified in ORS 743.417 (1)(a) and 743B.320; or
(b) Fifteen days prior to the end of the grace period specified in ORS 743.417 (1)(b).
(3) The Department of Consumer and Business Services may prescribe by rule the information that must be contained in the notice required by subsection (1) of this section. [Formerly 743.565; 2021 c.205 §11]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.324 - Rules for certain notice requirements.

The Director of the Department of Consumer and Business Services shall adopt rules necessary for the implementation and administration of ORS 743B.323 and the amendments to ORS 743.417, 743.420, 743B.013, 743B.105, 743B.125 and 743B.320 by sections 9 to 14, chapter 943, Oregon Laws 2001. [Formerly 743.566]
Note:
743B.324 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743B 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 743B - Health Benefit Plans: Individual and Group › Section 743B.330 - Notice to policyholder required for cancellation or nonrenewal of health benefit plan; effect of failure to give notice.

(1) As used in this section, "health benefit plan" has the meaning given that term in ORS 743B.005.
(2) An insurer shall notify a policyholder in writing if the insurer cancels or does not renew the policyholder’s individual health benefit plan. The notice shall be sent to the policyholder’s last-known mailing address by first class mail in a specially marked envelope or, if the policyholder has elected to receive communications from the insurer electronically, to the policyholder’s last-known electronic mail address using a mechanism that will confirm delivery to the address.
(3) If the cancellation or nonrenewal results in a refund to the policyholder of all or part of a premium, the insurer must mail with the refund a written explanation that includes:
(a) The effective date of the cancellation;
(b) The reason for the cancellation; and
(c) The time period to which the refund is applicable.
(4) For any cancellation or nonrenewal due to a reported death of the policyholder, the insurer must:
(a) Confirm the accuracy of the reported death.
(b) If the death is confirmed:
(A) Provide any dependents covered by the plan with information about how to continue coverage or obtain alternative coverage; and
(B) Issue any refund that is due to the estate of the deceased in accordance with subsection (3) of this section.
(5) If an insurer cancels or does not renew an individual health benefit plan and fails to comply with the requirements of this section, the insurer shall continue the coverage under the plan for the policyholder and any dependents covered by the plan until the date that the insurer has complied with the requirements of this section. The insurer shall waive any premiums owed for the period during which the coverage was continued under this subsection and shall process all claims incurred by the policyholder or any covered dependents according to the terms of the plan.
(6) This section does not apply:
(a) To a cancellation requested by the policyholder if the insurer documents the request and confirms the request with the policyholder;
(b) To a cancellation or nonrenewal that results from a policyholder making a change in coverage with the same insurer; or
(c) To a cancellation due to nonpayment of premium. [Formerly 743.499]
Note:
743B.330 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.341 - Continuation of benefits after termination of group health insurance policy; rules.

(1) Every group health insurance policy that provides coverage for hospital or medical services or expenses shall provide that the insurer shall continue its obligation for benefits under the policy for any person insured under the policy who is hospitalized on the date of termination if the policy is terminated and immediately replaced by a group health insurance policy issued by another insurer. Any payment required under this section is subject to all terms, limitations and conditions of the policy except those relating to termination of benefits. Any obligation by an insurer under this section continues until the hospital confinement ends or hospital benefits under the policy are exhausted, whichever is earlier.
(2) The Director of the Department of Consumer and Business Services may adopt rules providing for uninterrupted coverage for individuals insured under a group health insurance policy providing coverage for hospital or medical expenses, when such a policy is replaced by a policy of similar benefits, whether issued by the same insurer or another. [Formerly 743.529]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.342 - Continuation of benefits after injury or illness covered by workers’ compensation.

Every policy of group health insurance delivered or issued for delivery in this state shall contain a provision applicable to the coverage for hospital or medical services or expenses provided under the policy that if an employee incurs an injury or illness for which a workers’ compensation claim is filed, that policy will continue in effect with respect to that employee upon timely payment by the employee of the premium that includes the individual contribution and the contribution due from the employer under the applicable benefit plan. The employee may maintain such coverage until whichever of the following events first occurs:
(1) The employee takes full-time employment with another employer; or
(2) Six months from the date that the employee first makes payment under this section. [Formerly 743.530]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.343 - Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older.

(1) A group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall contain a provision that:
(a) The surviving spouse of a certificate holder may continue coverage under the policy, at the death of the certificate holder, with respect to the spouse and any dependent children whose coverage under the policy otherwise would terminate because of the death of the certificate holder if the surviving spouse is 55 years of age or older at the time of the death; and
(b) The divorced or legally separated spouse of a certificate holder may continue coverage under the policy, upon dissolution of marriage with, or legal separation from, the certificate holder, with respect to the divorced or legally separated spouse and any dependent children whose coverage under the policy otherwise would terminate because of the dissolution of marriage or legal separation, if the divorced or legally separated spouse is 55 years of age or older at the time of the dissolution or legal separation.
(2) Continued coverage for dental, vision care or prescription drug expenses shall be offered to legally separated, divorced or surviving spouses and any dependent children eligible under subsection (1) of this section if such coverage is or was available to the certificate holder. [Formerly 743.600]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.344 - Procedure for obtaining continuation of coverage under ORS 743B.343.

(1) As used in subsections (1) to (6) of this section, "plan administrator" means:
(a) The person designated as the plan administrator by the instrument under which the group health insurance plan is operated; or
(b) If no plan administrator is designated, the plan sponsor.
(2) Within 60 days of legal separation or the entry of a judgment of dissolution of marriage, a legally separated or divorced spouse eligible for continued coverage under ORS 743B.343 who seeks such coverage shall give the plan administrator written notice of the legal separation or dissolution. The notice shall include the mailing address of the legally separated or divorced spouse.
(3) Within 30 days of the death of a covered person whose surviving spouse is eligible for continued coverage under ORS 743B.343, the group policyholder shall give the plan administrator written notice of the death and of the mailing address of the surviving spouse.
(4) Within 14 days of receipt of notice under subsection (2) or (3) of this section, the plan administrator shall notify the legally separated, divorced or surviving spouse that the policy may be continued. The notice shall be mailed to the mailing address provided to the plan administrator and shall include:
(a) A form for election to continue the coverage;
(b) A statement of the amount of periodic premiums to be charged for the continuation of coverage and of the method and place of payment; and
(c) Instructions for returning the election form by mail within 60 days after the date of mailing of the notice by the plan administrator.
(5) Failure of the legally separated, divorced or surviving spouse to exercise the election in accordance with subsection (4) of this section shall terminate the right to continuation of benefits.
(6) If a plan administrator fails to notify the legally separated, divorced or surviving spouse as required by subsection (4) of this section, premiums shall be waived from the date the notice was required until the date notice is received by the legally separated, divorced or surviving spouse.
(7) The provisions of this section and ORS 743B.343 and 743B.345 apply only to employers with 20 or more employees and group health insurance plans with 20 or more certificate holders on a typical business day during the preceding calendar year. [Formerly 743.601]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.345 - Premium for continuation of coverage under ORS 743B.344; termination of right to continuation.

If a legally separated, divorced or surviving spouse elects continuation of coverage under ORS 743B.344 (1) to (6):
(1) The monthly premium for the continuation shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group plan plus the amount that the group policyholder would contribute toward the premium if the legally separated, divorced or surviving spouse were a certificate holder of the group plan, plus an additional amount not to exceed two percent of the certificate holder and group plan holder contributions, for the costs of administration.
(2) The first premium shall be paid by the legally separated, divorced or surviving spouse within 45 days of the date of the election.
(3) The right to continuation of coverage shall terminate upon the earliest of any of the following:
(a) The failure to pay premiums when due, including any grace period allowed by the policy;
(b) The date that the group policy is terminated as to all group members except that if a different group policy is made available to group members, the legally separated, divorced or surviving spouse shall be eligible for continuation of coverage as if the original policy had not been terminated;
(c) The date on which the legally separated, divorced or surviving spouse becomes insured under any other group health plan;
(d) The date on which the legally separated or divorced spouse remarries; or
(e) The date on which the legally separated, divorced or surviving spouse becomes eligible for federal Medicare coverage. [Formerly 743.602]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.400 - Decisions regarding health care facility length of stay, level of care and follow-up care.

(1) All clinical decisions regarding length of stay in a health care facility as defined in ORS 442.015, transfer between levels of care and follow-up care shall be the decision of the treating provider in consultation with the patient, as appropriate.
(2) An insurer may not terminate or restrict the practice privileges of any provider solely on the basis of one or more decisions made pursuant to subsection (1) of this section. [Formerly 743.829]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.403 - Insurer prohibited practices; patient communication and referral.

No insurer may terminate or otherwise financially penalize a provider for:
(1) Providing information to or communicating with a patient in a manner that is not slanderous, defamatory or intentionally inaccurate concerning:
(a) Any aspect of the patient’s medical condition;
(b) Any proposed treatment or treatment alternatives, whether covered by the insurer’s health benefit plan or not; or
(c) The provider’s general financial arrangement with the insurer.
(2)(a) Referring a patient to another provider, whether or not that provider is under contract with the insurer. If a provider refers a patient to another provider, the referring provider shall:
(A) Comply with the insurer’s written policies and procedures with respect to any such referrals; and
(B) Inform the patient that the referral services may not be covered by the insurer.
(b) Allocation of costs for referral services shall be a matter of contract between the provider and the insurer. Allocation of costs to the provider by contract shall not be considered a penalty under this section. [Formerly 743.834]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.406 - Vision care providers.

(1) As used in this section:
(a) "Contractual discount" means a percentage reduction, required under a contract with an insurer, in a vision care provider’s usual and customary rate for vision care services and materials.
(b) "Discount card" means a card or other purchasing mechanism or device that is not insurance or a discount medical plan, as defined in ORS 735.631, that purports to offer discounts or access to discounts in health-related purchases from health care providers.
(c) "Materials" includes, but is not limited to:
(A) Lenses;
(B) Devices containing lenses;
(C) Contact lenses;
(D) Prisms;
(E) Lens treatments and contact lens coatings;
(F) Orthopedic or prosthetic devices to correct, relieve or treat defects or abnormal conditions of the human eye or adnexa; and
(G) Vision training.
(d) "Vision care insurance" means a health benefit plan or a policy or certificate of insurance that covers vision care services and materials.
(e) "Vision care provider" includes:
(A) A person licensed to practice optometry under ORS chapter 683; and
(B) A physician licensed under ORS 677.100 to 677.228 to practice medicine who has completed a residency program in ophthalmology.
(f) "Vision care services" means services provided by a vision care provider within the scope of the provider’s license to practice optometry or ophthalmology.
(2) A contract between a vision care provider and an entity that offers vision care insurance or a vision care discount card may not:
(a) Limit or specify the fee that a vision care provider may charge for vision care services or materials that are not reimbursed, in whole or in part, by the vision care insurance or discount card.
(b) Require a vision care provider to participate in one vision care insurance plan or discount card program as a condition for participating in another insurance plan.
(c) Change the terms, the contractual discount or the reimbursement rates, under vision care insurance or a vision care discount card, without a signed acknowledgment that the vision care provider agrees to the changes.
(d) Directly or indirectly restrict or limit a vision care provider’s choice of suppliers of materials.
(3) This section does not prohibit the use of a discount card by a patient of a vision care provider if:
(a) The enrollment of the vision care provider is:
(A) Completely voluntary; and
(B) Not conditioned upon the vision care provider’s participation in any other discount card program with different provider terms and conditions or in another insurance plan; and
(b) The discount card program does not reimburse the vision care provider for the cost of the vision care services that were discounted. [2015 c.832 §2; 2017 c.409 §37]
Note:
743B.406 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.407 - Naturopathic physicians.

(1) An insurer shall provide a naturopathic physician the choice of applying to be credentialed by the insurer as a primary care provider or as a specialty care provider.
(2) To be credentialed by an insurer as a primary care provider, a naturopathic physician must meet the credentialing requirements as established by the insurer. [2015 c.224 §2]
Note:
743B.407 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.420 - Prior authorization requirements.

Except in the case of misrepresentation, prior authorization determinations shall be subject to the following requirements:
(1) Prior authorization determinations relating to benefit coverage and medical necessity shall be binding on the insurer if obtained no more than 60 days prior to the date the service is provided.
(2) Prior authorization determinations relating to enrollee eligibility shall be binding on the insurer if obtained no more than five business days prior to the date the service is provided. [Formerly 743.837; 2021 c.154 §4]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.422 - Utilization review requirements for medical services contracts to which insurer not party; right to appeal.

All utilization review performed pursuant to a medical services contract to which an insurer is not a party shall comply with the following:
(1) The criteria used in the review process and the method of development of the criteria shall be made available for review to a party to such medical services contract upon request.
(2) A physician licensed under ORS 677.100 to 677.228 shall be responsible for all final recommendations regarding the necessity or appropriateness of services or the site at which the services are provided and shall consult as appropriate with medical and mental health specialists in making such recommendations.
(3) Any patient or provider who has had a request for treatment or payment for services denied as not medically necessary or as experimental shall be provided an opportunity for a timely appeal before an appropriate medical consultant or peer review committee.
(4) Except as provided in subsection (5) of this section, a determination on a provider’s or an enrollee’s request for prior authorization of a nonemergency service must be issued within a reasonable period of time appropriate to the medical circumstances but no later than two business days after receipt of the request, and qualified health care personnel must be available for same-day telephone responses to inquiries concerning certification of continued length of stay.
(5) If additional information from an enrollee or a provider is necessary to make a determination on a request for prior authorization, no later than two business days after receipt of the request, the enrollee and the provider shall be notified in writing of the specific additional information needed to make the determination. The determination must be issued by the later of:
(a) Two business days after receipt of a response to the request for additional information; or
(b) Fifteen days after the date of the request for additional information unless otherwise provided by federal law. [Formerly 743.806; 2017 c.409 §38; 2019 c.284 §3; 2021 c.205 §12]
Note:
See note under 743B.405.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.424 - Applicability.

The provisions of ORS 743B.001, 743B.220, 743B.405 and 743B.422 do not apply to medical services contracts for services to be provided under ORS chapter 656. [Formerly 743.811]
Note:
See note under 743B.405.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.425 - Prohibited restrictions on coverage of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs; exceptions.

(1) An insurer offering a health benefit plan as defined in ORS 743B.005 may not:
(a) Require prior authorization:
(A) During the first 60 days of treatment, including medication therapy, prescribed for opioid or opiate withdrawal; or
(B) For post-exposure prophylactic antiretroviral drugs or at least one preexposure prophylactic antiretroviral drug;
(b) Restrict the reimbursement for medication therapies, preexposure prophylactic antiretroviral drugs or post-exposure prophylactic antiretroviral drugs to in-network pharmacists or pharmacies; or
(c) Subject to ORS 742.008, require a deductible, copayment, coinsurance or other cost-sharing for the coverage of human immunodeficiency virus post-exposure prophylactic drugs or therapies prescribed following a possible exposure to human immunodeficiency virus.
(2) This section is not subject to ORS 743A.001.
(3) This section does not prohibit prior authorization for opioids or opiates prescribed for purposes other than medication therapy or treatment of opioid or opiate abuse or addiction.
(4) Subsection (1)(b) of this section does not apply to a health maintenance organization as defined in ORS 750.005. [2017 c.683 §4; 2021 c.365 §5; 2023 c.411 §3]
Note:
743B.425 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.450 - Prompt payment of claims; limits on use of electronic payment methods; rules.

(1) Except as provided in this subsection, when a claim under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim. If an insurer requires additional information before payment of a claim, not later than 30 days after the date on which the insurer receives the claim, the insurer shall notify the enrollee and the provider in writing and give the enrollee and the provider an explanation of the additional information needed to process the claim. The insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the additional information.
(2) A contract between an insurer and a provider may not include a provision governing payment of claims that limits the rights and remedies available to a provider under this section and ORS 743B.452 or has the effect of relieving either party of its obligations under this section and ORS 743B.452.
(3) An insurer may pay a claim using a credit card or electronic funds transfer payment method that imposes on the provider a fee or similar charge to process the payment if:
(a) The insurer notifies the provider, in advance, of the fee or other charges associated with the use of the credit card or electronic funds transfer payment method;
(b) The insurer offers the provider an alternative payment method that does not impose fees or similar charges on the provider; and
(c) The provider or a designee of the provider elects to accept a payment of the claim using the payment method.
(4) An insurer shall establish a method of communicating to providers the procedures and information necessary to complete claim forms. The procedures and information must be reasonably accessible to providers.
(5) This section does not create an assignment of payment to a provider.
(6) Each insurer shall report to the Director of the Department of Consumer and Business Services on its compliance under this section according to requirements established by the director.
(7) The director shall adopt by rule a definition of "clean claim" and shall consider the definition of "clean claim" used by the federal Department of Health and Human Services for the payment of Medicare claims. [Formerly 743.911]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.452 - Interest on unpaid claims.

(1) An insurer that fails to pay a claim to a provider within the timelines established in ORS 743B.450 shall pay simple interest of 12 percent per annum on the unpaid amount of the claim that is due and owing, accruing from the date after the payment was due until the claim is paid. Interest on any overdue payment for a claim begins to accrue on the 31st day after:
(a) The date on which the insurer received the claim; or
(b) The date the insurer receives the requested additional information.
(2) The interest is payable with the payment of the claim. An insurer is not required to pay interest that is in the amount of $2 or less on any claim.
(3) The availability of interest under subsection (1) of this section is in addition to and not in lieu of administrative actions and penalties that may be imposed by the Director of the Department of Consumer and Business Services under the Insurance Code. [Formerly 743.913]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.453 - Underpayment of claims.

(1) Except in the case of fraud and except as provided in subsection (3) of this section, a health care provider may not:
(a) Request additional payment from a health insurer to satisfy a claim unless the provider:
(A) Requests the additional payment in writing on or before the last day of the period specified by the contract or 18 months after the date the claim was denied or payment intended to satisfy the claim was made, whichever is earlier; and
(B) Specifies in the written request why the provider believes the health insurer owes the additional payment.
(b) Request that an additional payment be paid earlier than six months after the health insurer receives the request.
(2) A health insurer may not consider a health care provider’s claim untimely if the claim is made no later than 12 months after a different insurer:
(a) Denied the claim in whole or in part; or
(b) Requested a refund of an erroneous payment made on the claim.
(3) A health care provider may not do the following for reasons related to coordination of benefits with another health insurer or entity responsible for payment of a claim:
(a) Request additional payment from a health insurer to satisfy a claim unless the provider:
(A) Requests the additional payment in writing within 30 months after the date the claim was denied or payment intended to satisfy the claim was made;
(B) Specifies in the written request why the provider believes the health insurer owes the additional payment; and
(C) Includes in the written request the name and mailing address of the other health insurer or entity that has disclaimed responsibility for payment of the claim.
(b) Request that the additional payment be paid earlier than six months after the health insurer receives the request.
(4) If a contract between a health insurer and a health care provider conflicts with this section, the provisions of this section prevail. However, nothing in this section prohibits a health insurer from choosing at any time to make additional payments to a health care provider to satisfy a claim.
(5) This section applies to health benefit plans. [Formerly 743.917]
Note:
743B.453 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.456 - Limits on use of electronic payment methods for reimbursement of dental claims.

(1) As used in this section, "dental insurer" means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit.
(2) A dental insurer may pay a claim for reimbursement made by a dental care provider using a credit card or electronic funds transfer payment method that imposes on the provider a fee or similar charge to process the payment if:
(a) The dental insurer notifies the provider, in advance, of the potential fees or other charges associated with the use of the credit card or electronic funds transfer payment method;
(b) The dental insurer offers the provider an alternative payment method that does not impose fees or similar charges on the provider; and
(c) The provider or a designee of the provider elects to accept a payment of the claim using the credit card or electronic funds transfer payment method.
(3) If a dental insurer contracts with a vendor to process payments of dental providers’ claims, the dental insurer shall require the vendor to comply with the provisions of subsection (2)(a) of this section. [2023 c.425 §2]
Note:
743B.456 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.458 - Performance-based incentive payments for primary care.

An insurer offering a health benefit plan, as defined in ORS 743B.005, that reimburses 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-based incentive payments for primary care, shall offer similar alternative payment methodologies to reimburse the costs of services provided by patient centered primary care homes identified in accordance with ORS 413.259 that serve beneficiaries of the health benefit plan. [2017 c.489 §7]
Note:
743B.458 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.460 - Conditions for restricting payments to only in-network providers.

(1) An insurer may negotiate and enter into contracts for alternative rates of payment with providers to provide services covered by a group health insurance policy and may offer the benefit of such alternative rates to insureds who select such providers. An insurer may utilize such contracts by offering a choice of plans at the time an insured enrolls, one of which provides benefits only for services by members of a particular provider organization with whom the insurer has an agreement. If an insured chooses such a plan, benefits are payable only for services rendered by a member of that provider organization, unless such services were requested by a member of such organization or are rendered as the result of an emergency.
(2) Benefits paid by an insurer to a provider under subsection (1) of this section shall discharge the insurer’s obligation with respect to the amount of insurance so paid.
(3) Insurers shall provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates under their group policy and shall also make such lists available for public inspection during regular business hours at the insurer’s principal office within this state. [Formerly 743.531]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.462 - Direct payments to providers.

(1) As used in this section:
(a) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(b) "Provider" means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services, including substance use disorder services, in the ordinary course of business or practice of a profession.
(2) Except as provided in ORS 743.543 and 743.550, a provider that bills an insurer for covered services provided to an individual who is insured under a health benefit plan or a Medicare supplement insurance policy issued by the insurer shall be reimbursed by the insurer by a direct payment issued to the provider. [2015 c.588 §2]
Note:
743B.462 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.501 - Registration of contracting entity.

(1) A contracting entity that does not have a certificate of authority shall register with the Department of Consumer and Business Services as a contracting entity by submitting the following information to the department in written or electronic form as prescribed by the department along with any fee prescribed by the department:
(a) The official name of the entity and any secondary, alternative or substitute designations.
(b) The mailing address and telephone number of the headquarters of the entity.
(c) The name and telephone number of a representative of the entity who shall serve as the primary contact for the department.
(2) The requirements of this section do not apply to a contracting entity that is under common ownership and control of a contracting entity that is licensed by or has a certificate of authority from the department. [Formerly 743.083]
Note:
743B.501 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.503 - Additional requirements for third party contracts.

(1) A contract between a third party and a contracting entity or between two third parties with respect to a provider network contract must comply with this section and ORS 743B.502.
(2)(a) A third party shall inform the contracting entity and providers under a contracting entity’s provider network contract of a website, toll-free number or other readily available mechanism to identify the names of all third parties to which the third party provides access to the health care services and discounted rates of a provider under the provider network contract.
(b) The third party shall update the website described in paragraph (a) of this subsection at least every 90 days to reflect all third parties currently provided access. Upon request, the third party shall make the information available to a provider via telephone or through direct notification.
(3) A provider may refuse to accept as payment in full a discounted payment made by a third party under the terms of a provider network contract if there is no valid contractual basis for the discount or the discount is taken in violation of this section or ORS 743B.502. [Formerly 743.086]
Note:
See note under 743B.500.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.550 - Disclosure of information.

Nothing in ORS 743.008, 743A.012, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.250, 743B.400, 743B.403, 743B.420, 743B.423 and 743B.550 shall be construed to require disclosure of information that is otherwise privileged or confidential under any other provision of law. [Formerly 743.839; 2021 c.97 §83]