reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1130 - Annual Summary, Utilization Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To comply with the requirements of ORS
			 743.807, an insurer must
			 electronically submit on or before June 30 of each calendar year, an annual
			 utilization review program summary for the preceding calendar year to the
			 Division of Financial Regulation in the format required by the director of the
			 Department of Consumer and Business Services as set forth on the website of the
			 Division of Financial Regulation of the Department of Consumer and Business
			 Services at dfr.oregon.gov. Filing and reporting requirements in this rule
			 apply to:
(a) A domestic insurer;
			 and
(b) A foreign insurer
			 transacting $2 million or more in health benefit plan premium in Oregon during
			 the calendar year immediately preceding the due date of a required
			 report.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1140 - Appeal, Utilization Review Determinations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When a provider first appeals the
			 decision of an insurer to deny treatment or payment for services as not
			 medically necessary or experimental under ORS
			 743.807(2)(c):
(a) The insurer shall acknowledge receipt of
			 the notice of appeal not later than the seventh day after receiving the notice;
			 and
(b) An appropriate medical
			 consultant or peer review committee shall review the appeal and decide the
			 issue not later than the 30th day after the insurer receives notice of the
			 appeal.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1170 - Annual Summary, Quality Assessment Activities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The annual summary required by ORS
			 743.814(2)
			 shall:
(a) Describe the insurer's quality
			 assessment program that enables the insurer to evaluate, maintain and improve
			 the quality of health services provided to enrollees;
(b) Identify the specific quality-improvement
			 goals chosen by the insurer and report any progress on those goals as measured
			 by the insurer's data gathering;
(c) Describe the insurer's quality assessment
			 activities, to the extent the insurer engages in relevant activities, in the
			 following areas:
(A) Corporate
			 oversight;
(B) Credentialing of
			 providers;
(C) Provider
			 participation;
(D) Use of clinical
			 practice guidelines;
(E)
			 Identification of priorities;
(F)
			 Assessment of enrollee satisfaction;
(G) Communication with enrollees and
			 providers;
(H) Program
			 evaluation.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1180 - Format and Instructions for Report Required by ORS 743.818

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 rule:
(a) "Covered lives" means Oregon
			 residents who are employees, dependents of employees, or individuals otherwise
			 eligible for an individual, student health, association, group, or self-insured
			 group health benefit plan or other benefit plan for which reporting is required
			 and who are enrolled for coverage under the terms of the plan as of the close
			 of the calendar quarter.
(b)
			 "Carrier" has the meaning given that term in ORS
			 743.730(7).
(c) "Zip code" means the 5-digit code:
(A) Of the employee or individual
			 policyholder's Oregon residence;
(B) Of an Oregon employer group covered by a
			 stop loss policy; or,
(C) In
			 circumstances for which no Oregon zip codes exists, the placeholder code
			 established by the director of the Department of Consumer and Business Services
			 set forth on the website of the Division of Financial Regulation of the
			 Department of Consumer and Business Services at dfr.oregon.gov.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1190 - Annual Summary, Uniform Indicators of Network Adequacy

Current through Register Vol. 63, No. 7, July 1, 2024
An insurer offering managed health insurance or preferred
				provider organization insurance shall submit its annual summary required under
				ORS 743.817 on March 1 of each year.
				The annual summary shall include the following matters for the immediately
				preceding calendar year as of December 31, according to the following uniform
				indicators:
(1) Whether the insurer
			 has established a requirement or goal for accessibility that providers must
			 meet, in terms of hours, days or weeks, or in the alternative an indication
			 that the insurer does not establish and maintain such a requirement or goal,
			 for the following categories:
(a) Preventive
			 care;
(b) Routine primary care;
			 and
(c) Urgent care.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1200 - Prior Authorization Requirements for Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The provisions
			 of this rule implement the requirements of ORS
			 743B.420,
			 ORS
			 743B.422 and ORS
			 743B.423,
			 as well amendments to ORS
			 743B.420 and ORS
			 743B.423 by Oregon Laws 2021, chapter 154 relating to prior authorization
			 determinations. "Prior authorization" means a form of utilization review that
			 requires a provider or an enrollee to request a determination by an insurer,
			 prior to provision of health care that is subject to utilization review, that
			 the insurer will provide reimbursement for the health care requested. "Prior
			 authorization" does not include referral approval for evaluation and management
			 services between providers. For the purposes of this rule, "health care"
			 includes all items and services covered by a health benefit plan, including but
			 not limited to medical, behavioral health, dental and vision care items and
			 services.
(2) This rule applies to
			 prior authorization determinations that:
(a)
			 Are issued orally or in writing by an insurer to a provider or enrollee
			 regarding the benefit coverage or medical necessity of a health care item or
			 service to be provided to an enrollee; and
(b) Are required under and obtained in
			 accordance with the terms of a health benefit plan.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1203 - Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The purpose
			 of this rule is to establish standards for determining whether an insurer
			 offering a policy or certificate of health insurance, other than a health
			 benefit plan, acts promptly in response to a request for prior authorization
			 within the meaning of ORS
			 746.233(2)(e).
			 Nothing in this rule shall be construed to limit the department's authority
			 under this section to require a health insurer to act equitably and in good
			 faith with respect to approving requests for prior authorization.
(2) "Prior authorization" means a form of
			 utilization review that requires a provider or an enrollee to request a
			 determination by an insurer, prior to provision of health care that is subject
			 to utilization review, that the insurer will provide reimbursement for the
			 health care requested. "Prior authorization" does not include referral approval
			 for evaluation and management services between providers. For the purposes of
			 this rule, "health care" includes all items and services covered by a policy or
			 certificate of health insurance, including but not limited to medical,
			 behavioral health, dental and vision care items and services.
(3) This rule applies to prior authorization
			 determinations that:
(a) Are issued orally or
			 in writing to a provider or enrollee by an insurer offering a policy or
			 certificate of health insurance, other than a health benefit plan, regarding
			 the benefit coverage or medical necessity of a health care item or service to
			 be provided to an enrollee; and
(b)
			 Are required under and obtained in accordance with the terms of a health
			 insurance plan.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1205 - Uniform Prescription Drug Prior Authorization Request Form

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 rule:
(a) "Material information" means
			 information that is:
(A) Related to the
			 patient's clinical condition sufficient to enable an individual with the
			 appropriate training and experience to determine whether the prescription
			 authorization request should be approved or disapproved; or
(B) Required by state or federal law for
			 dispensing restricted prescription drugs.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1300 - Purpose and Scope; Application

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-1300  to 836-053-1365  are
			 adopted by the Director of the Department of Consumer and Business Services to
			 implement ORS
			 743B.252 to
			 743B.256,
			 governing the Director's contracting with independent review organizations for
			 the purpose of resolving disputes relating to adverse decisions by insurers in
			 one or more of the issues specified in 743B.252.
(2) OAR 836-053-1300  to 836-053-1365  are
			 operative with respect to disputes for which the initial grievance is filed on
			 or after July 1, 2002 under health benefit plans in existence, issued or
			 renewed on or after July 1, 2002.
Statutory/Other Authority: ORS
				  731.244 & 743B.253 -
				  743B.256
Statutes/Other Implemented: ORS
				  743B.252 -
				  743B.256
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1305 - Definitions; Authority to Act for Enrollee

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in OAR 836-053-1300  to
			 836-053-1365, "medical reviewer" means any of the following persons who is
			 assigned to an independent review case by an independent review organization:
(a) A doctor of medicine or osteopathy
			 licensed under ORS Chapter 677 or under the laws of another state.
(b) A provider as defined in ORS
			 743B.001(16)(a)(b).
(c) A health care professional licensed,
			 certified or otherwise authorized or permitted by the laws of another state to
			 administer medical or mental health services in the ordinary course of business
			 or practice of a profession.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1310 - Contracting Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be
			 considered for contracting with the Director of the Department of Consumer and
			 Business Services as an independent review organization under ORS
			 743B.253 for the purpose of providing independent review under 743B.252, an independent
			 review organization must submit to the director a response to the director's
			 request for proposal according to its requirements. The response must include:
(a) For an independent review organization
			 that is publicly held, the name of each stockholder or owner of more than five
			 percent of any stock or options;
(b) The name of any holder of bonds or notes
			 of the independent review organization that exceed $100,000;
(c) The name and type of business of each
			 corporation or other organization that the independent review organization
			 controls or is affiliated with and the nature and extent of the affiliation or
			 control;
(d) The name and a
			 biographical sketch of each director, officer and executive of the independent
			 review organization and any entity listed under subsection (c) of this section
			 and a description of any relationship the named individual has with:
(A) An insurer;
(B) A utilization review agent;
(C) A nonprofit or for-profit hospital or
			 other health care corporation;
(D)
			 A doctor of medicine or osteopathy, a provider or other health care
			 professional;
(E) A drug or device
			 manufacturer; or
(F) A group
			 representing any of the entities described by paragraph (A) to (E) of this
			 subsection;
(e) The
			 percentage of the independent review organization's revenues that the
			 independent review organization anticipates will be derived from reviews
			 conducted under ORS
			 743B.256;
(f) A description of the areas of expertise
			 of the medical reviewers making review determinations for the independent
			 review organization, as well as policies and standards of the independent
			 review organization that address qualifications, training and assignment of all
			 types of medical reviewers and that are compliant with requirements of OAR
			 836-053-1317;
(g) The procedures
			 that the independent review organization will use in making review
			 determinations regarding reviews conducted under ORS
			 743B.256;
(h) Attestations that all requirements will
			 be met;
(i) Evidence of
			 accreditation by a nationally recognized private accrediting
			 organization;
(j) Other
			 documentation, including but not limited to legal and financial information,
			 policies and procedures, and data that are pertinent to requirements of ORS
			 743B.256 and OAR 836-053-1315; and
(k) Any
			 other requirements established by the director that demonstrate the independent
			 review organization's ability to meet all requirements for contracting as an
			 independent review organization in this state.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1315 - Performance Criteria

Current through Register Vol. 63, No. 7, July 1, 2024
The following are performance criteria that an independent
				review organization must satisfy when demonstrating its eligibility for
				contracting with the Director of the Department of Consumer and Business
				Services to perform independent review responsibilities under ORS
				743B.256,
				and in order to continue performing those responsibilities under the contract
				with the director. For purposes of this rule, an independent review
				organization must:
(1) Demonstrate its
			 capability of and expertise in reviewing health care, and a history of such
			 review, in terms of the coverage issues that are subject to independent review
			 pursuant to ORS
			 743B.252,
			 in terms of the application of other health plan coverage provisions and in
			 terms of health insurance contract law.
(2) Demonstrate the ability to handle a full
			 range of review cases occurring in this state. An independent review
			 organization may contract with a more specialized review organization, but the
			 independent review organization must ensure that each review conducted meets
			 all the requirements of ORS
			 743B.252,
			 743B.253 and
			 743B.256 and OAR 836-053-1300  to 836-053-1365.
(3) Comply with all conflict of interest
			 provisions in OAR 836-053-1320.
(4)
			 Maintain and assign an adequate number and range of qualified medical reviewers
			 in compliance with OAR 836-053-1310  and 836-053-1315  in order to:
(a) Make determinations regarding the full
			 range of independent review cases occurring in this state under ORS
			 743B.252;
			 and
(b) Meet timelines specified in
			 ORS
			 743B.256 and OAR 836-053-1340, including timelines for expedited review.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1317 - Professional Qualifications

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the
			 laws of another state that govern the licensing of doctors of medicine or
			 osteopathy shall be responsible for each final independent review determination
			 made by an independent review organization, and in making a determination shall
			 consult with other medical reviewers as appropriate.
(2) An independent review organization shall
			 have a medical director who holds a current unrestricted license as a medical
			 doctor or osteopathic physician and has had experience in direct patient care.
			 The medical director shall provide guidance for clinical aspects of the
			 independent review process and oversee the independent review organization's
			 quality assurance and credentialing programs.
(3) An independent review organization shall
			 maintain policies and practices that assure that each medical reviewer:
(a) Holds a current, unrestricted license,
			 certification or registration in this state, or current, unrestricted
			 credentials from another state;
(b)
			 Has at least five years of recent clinical experience;
(c) Is certified by an appropriate member
			 board of the American Board of Medical Specialties if board certification is
			 available for the specialty or profession in which the medical reviewer is
			 engaged; and
(d) Has the ability to
			 apply scientific standards of evidence in judging research literature pertinent
			 to review issues, as demonstrated through relevant training or professional
			 experience.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1320 - Conflict of Interest

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 independent review organization:
(a) Must not
			 be a subsidiary of, or in any way owned or controlled by, an insurer or an
			 association of insurers or of doctors, providers or other health care
			 professionals;
(b) Must provide
			 information to the Director of the Department of Consumer and Business Services
			 on its own organizational affiliations and potential conflicts of interest at
			 the time of its response to the director's request for proposals and thereafter
			 when material changes occur;
(c)
			 Must immediately turn down a case referred by the director if accepting it
			 would constitute an organizational conflict of interest; and
(d) Must ensure that medical reviewers are
			 free from any actual or potential conflict of interest in assigned
			 cases.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1325 - Procedures for Conducting External Reviews

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An independent review organization is
			 subject to the following decision-making standards and procedures:
(a) The independent review process is
			 intended to be neutral and independent of influence by any affected party or by
			 state government. The Director of the Department of Consumer and Business
			 Services may conduct investigations as authorized by law but has no involvement
			 in the disposition of specific cases.
(b) Independent review is a document review
			 process. An enrollee, a health plan or an attending provider may not
			 participate in or attend an independent review in person or obtain
			 reconsideration of a decision by an independent review organization.
(c) An independent review organization shall
			 present cases to medical reviewers in a way that maximizes the likelihood of a
			 clear, unambiguous decision. This may involve stating or restating the
			 questions for review in a clear and precise manner that encourages yes or no
			 answers.
(d) An independent review
			 organization may uphold an adverse determination if the patient or any provider
			 refuses or fails to provide in a timely manner relevant medical records that
			 are available and have been requested pursuant to ORS
			 743B.256.
			 Pursuant to ORS
			 743B.252,
			 an independent review organization may overturn an adverse determination if the
			 insurer refuses or fails to provide in a timely manner relevant medical records
			 that are available and have been requested.
(e) An independent review organization must
			 maintain written policies and procedures covering all aspects of
			 review.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1330 - Criteria and Considerations for External Review Determinations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following
			 criteria and considerations apply to decisions by an independent review
			 organization:
(a) An independent review
			 organization must use fair procedures in making a decision, and the decision
			 must be consistent with the standards in ORS
			 743B.253 and
			 743B.256 and OAR 836-053-1300  to 836-053-1365.
(b) An independent review organization may
			 override the standards of a health benefit plan governing the coverage issues
			 that are subject to independent review pursuant to ORS
			 743B.252(1)
			 only if the standards are determined upon review to be unreasonable or
			 inconsistent with sound, evidence-based medical practice.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1335 - Procedures for Complaint Investigation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Director of the Department of
			 Consumer and Business Services may audit, examine and conduct an on-site review
			 of records to investigate complaints alleging that an independent review
			 organization or medical reviewer committed conduct contrary to ORS
			 743B.253 or
			 743B.256,
			 or OAR 836-053-1300  to 836-053-1365  or the contract between the director and
			 the independent review organization.
(2) In addition to the procedures for an
			 enrollee to submit information about an independent review organization's
			 decision in OAR 836-053-1325, a person, including, but not limited to, an
			 enrollee, insurer or provider, may submit a written complaint to the director
			 alleging that an independent review organization committed conduct described in
			 this rule. The director may consider the complaint in relation to the terms of
			 the contract with the independent review organization and in relation to ORS
			 743B.253 or
			 743B.256 and OAR 836-053-1300  to 836-053-1365  and take action as appropriate under the
			 contract. The director shall notify the complainant of the results of the
			 director's determinations and of any action taken or to be taken.
Statutory/Other Authority: ORS
				  731.244 & ORS
				  743B.253
Statutes/Other Implemented: ORS
				  743B.253  & ORS
				  743B.256
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1337 - Preliminary Review by Insurer

Current through Register Vol. 63, No. 7, July 1, 2024
When an enrollee applies to an insurer for independent review
				of a dispute, the insurer shall review the application and advise the enrollee
				that the application does or does not meet any of the criteria for independent
				review. The insurer shall send the application to the independent review
				organization as provided in ORS
				743B.252 unless the enrollee withdraws the application.
Statutory/Other Authority: ORS
				  731.244 & OR
				  743B.253
Statutes/Other Implemented: ORS
				  743B.255
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1342 - Timelines and Notice for Expedited Decision-Making

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When an insurer expedites an enrollee's
			 case under ORS
			 743B.252(5),
			 the insurer shall inform the Director of the Department of Consumer and
			 Business Services and the independent review organization that the referral is
			 expedited. If information on whether a referral is expedited is not provided to
			 the independent review organization, the independent review organization may
			 presume that the referral is not an expedited review, but the independent
			 review organization may request clarification from the insurer.
(2) The insurer and the director must
			 expedite an external review that is required to be expedited under ORS
			 743B.252(5)
			 when:
(a) An enrollee requests external
			 review before the enrollee has exhausted all internal appeals; or
(b) An enrollee simultaneously requests an
			 expedited internal appeal and an expedited external review.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1345 - Quality Assurance Mechanisms

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 An independent review organization must have a quality assurance program that
			 ensures the timeliness, quality of review and communication of determinations
			 to enrollees and insurers. The program must also ensure the qualifications,
			 impartiality and freedom from conflict of interest of the organization, its
			 staff and medical reviewers. The quality of review of an independent review
			 organization includes the use of appropriate methods to match the case,
			 confidentiality and systematic evaluation of complaints for patterns or
			 trends.
(2) A quality assurance
			 program must include a written plan addressing its scope and objectives;
			 program organization, monitoring and oversight mechanisms; and evaluation and
			 organizational improvement of independent review organization activities.
			 Organizational improvement must include the implementation of action plans to
			 improve or correct identified problems, and communication of the results of
			 action plans to staff and medical reviewers.
(3) An independent review organization shall
			 record complaints in a log. The log shall include for each complaint the nature
			 of the complaint and how it was resolved. Upon request, the independent review
			 organization shall provide the log and complaints to the director for
			 review.
Statutory/Other Authority: ORS
				  743B.253  & ORS
				  731.244
Statutes/Other Implemented: ORS
				  743B.253
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1350 - Ongoing Requirements for Independent Review Organizations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An independent
			 review organization shall file an annual statistical report with the Director
			 of the Department of Consumer and Business Services, on a form specified by the
			 director, that summarizes reviews conducted. The report shall include, but need
			 not be limited to, volumes, types of cases, compliance with timelines for
			 expedited and non-expedited cases, determinations, number and nature of
			 complaints and compliance with conflict of interests rules.
(2) An independent review organization shall
			 submit updated information to the director if at any time there is a material
			 change in the information included in the response of the independent review
			 organization to the director's request for proposals.
(3) An independent review organization shall
			 maintain records of all materials, including materials submitted by all
			 parties, notifications, documents relied upon, and the independent review
			 organization's ultimate decision for a period of not less than three years
			 after any review. The independent review organization shall provide copies of
			 any of these documents to the director upon request.
Statutory/Other Authority: ORS
				  731.244, ORS
				  743B.252,
				  ORS
				  743B.253  & ORS
				  743B.256
Statutes/Other Implemented: ORS
				  743B.253  & ORS
				  743B.256
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1355 - Synopses

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The synopses of
			 decisions required to be filed by independent review organizations under ORS
			 743B.256(5)
			 with the Director of the Department of Consumer and Business Services must meet
			 the requirements of this rule.
(2)
			 Synopses of decisions shall include the following for each decision:
(a) A description of the dispute sought to be
			 reviewed by the independent review organization, including whether the dispute
			 is alleged to concern the determination of medical necessity or experimental or
			 investigational treatment, whether an active course of treatment is occurring
			 for the purpose of determining whether a person is eligible for continuity of
			 care, or whether the dispute concerns some other issue.
(b) A determination by the independent review
			 organization whether the dispute falls within any of the categories of issues
			 that are eligible for independent review.
(c) A determination of the dispute by the
			 independent review organization in favor of the insurer or enrollee.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1360 - External Review Reporting

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each
			 independent review organization shall maintain written records in the aggregate
			 and by insurer on all requests for external review for which it conducted an
			 external review for the Director of the Department of Consumer and Business
			 Services during a calendar year.
(2) Each independent review organization
			 shall submit to the director, by March 31 of each year for the preceding
			 calendar year, a report in the format specified by the director. The report
			 shall include the information required by this section in the aggregate, for
			 each insurer, for Oregon external reviews only. The information to be included
			 in the report as provided in this section is as follows:
(a) The total number of requests for external
			 review received during the reporting period;
(b) The number of requests for external
			 review for which the independent review organization has made a final decision
			 and, of those requests, the number that uphold the insurer's final adverse
			 determination;
(c) The average
			 length of time for final decision by the independent review organization of:
(A) Disputes other than expedited disputes;
			 and
(B) Expedited
			 disputes.
(d) A summary
			 of the types of coverages or cases for which an external review was
			 sought;
(e) The number of requests
			 for which the independent review organization decided that it did not have
			 jurisdiction under ORS
			 743B.252.
(f) The number of external review cases that
			 were terminated as the result of a reconsideration by the insurer of the
			 insurer's final adverse determination after the receipt of additional
			 information from the enrollee or the enrollee's designated representative;
			 and
(g) Any other information the
			 director requests or requires.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1365 - Fees for External Reviews

Current through Register Vol. 63, No. 7, July 1, 2024
Fees to be imposed by an independent review organization for
				its external review of disputes shall be as determined in the competitive
				solicitation process, but shall be as low as is feasible in the request for
				proposal process. Fees shall be separately established for initial
				jurisdictional decisions by an independent review organization and for
				decisions that call for a more extended review.
Statutory/Other Authority: ORS
				  731.244 & ORS
				  743B.253
Statutes/Other Implemented: ORS
				  743B.253
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1400 - Format and Instructions for Report Required by ORS 743.748

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A carrier shall
			 submit the information required by ORS
			 743.748 electronically in the
			 format and according to the directions established by the Director of the
			 Department of Consumer and Business Services and made available on the website
			 of the Insurance Division, and according to the provisions of this
			 rule.
(2) The following terms used
			 in ORS 743.748have the following meanings for the purpose of the information
			 required by ORS 743.748. References in this
			 section to specific schedules and instructions are to schedules and
			 instructions for the NAIC health annual statement blank. The terms are defined
			 as follows:
(a) "Average amount of premiums
			 per member per month" means total earned premiums as reported on the exhibit of
			 premiums, enrollment and utilization divided by the total member months for the
			 required reporting year.
(b)
			 "Carrier's annual report" is the carrier's annual statement submitted as
			 required by ORS 731.574.
(c) "Medical loss ratio" means the total
			 medical claims cost divided by the total premiums earned, both as reported on
			 the exhibit of premiums, enrollment and utilization.
(d) "Percentage change in the average premium
			 per member per month" means the average amount of premiums per member per month
			 for the reporting year less the average premium per member per month for the
			 preceding reporting year divided by the average premium per member per month
			 for the preceding reporting year.
(e) "Total amount of costs for claims" means
			 incurred claims as reported by the carrier on the exhibit of premiums,
			 enrollment and utilization in its annual statement. If the annual statement
			 blank used by a carrier does not include an exhibit of premiums, enrollment and
			 utilization, the carrier shall derive the answer from its records, using the
			 instructions for the exhibit of premiums, enrollment and utilization for
			 reporting the information.
(f)
			 "Total amount of premiums" means earned premium as reported by the carrier on
			 the exhibit of premiums, enrollment and utilization in its annual statement. If
			 the annual statement blank used by a carrier does not include an exhibit of
			 premiums, enrollment and utilization, the carrier shall derive the answer from
			 its records, using the instructions for the exhibit of premiums, enrollment and
			 utilization for reporting the information.
(g) "Total number of members" means total
			 number of members as of December 31 of the reporting year, as reported by the
			 carrier in its annual statement. If the annual statement blank used by a
			 carrier does not include an exhibit of premiums, enrollment and utilization,
			 the carrier shall derive the answer from its records, using the instructions
			 for the exhibit of premiums, enrollment and utilization for reporting the
			 information.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1403 - Definitions of Coordinated Care and Case Management for Behavioral Health Care Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 definitions set forth in ORS
			 743A.168 apply to the use of
			 those terms in these rules.
(2)
			 "Caring contacts" mean brief communications with a patient that start during
			 care transition such as discharge or release from treatment, or when a patient
			 misses an appointment or drops out of treatment, and continues as long as a
			 qualified mental health professional deems necessary.
(3) "Case management" means the management of
			 services that are provided to assist an individual in accessing medical and
			 behavioral health care, social and educational services, public assistance and
			 medical assistance and other needed community services identified in the
			 individual's patient-centered care plan.
(4) "Coordination of care" means the process
			 of coordinating patient care activities as well as the facilitation of ongoing
			 communication and collaboration with lay caregivers by community resource
			 providers, health care providers, and agencies to meet the multiple needs of a
			 patient by:
(a) Organizing and participating
			 in team meetings; and
(b) Ensuring
			 continuity of care during each transition of care.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1404 - Definitions; Noncontracting Providers; Co-Morbidity Disorders

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in ORS
			 743A.168 and OAR Chapter 836:
(a) "Behavioral health condition" means any
			 mental or substance use disorder covered by diagnostic categories listed in the
			 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text
			 Revision (DSM-5-TR), the International Classification of Diseases, 10th
			 Revision (ICD-10), or the International Classification of Diseases, 11th
			 Revision (ICD-11).
(b) "Generally
			 accepted standards of care" means;
(A)
			 Standards of care and clinical practice guidelines that:
(i) Are generally recognized by health care
			 providers practicing in relevant clinical specialties; and
(ii) Are based on valid, evidence-based
			 sources; and
(B)
			 Products and services that:
(i) Address the
			 specific needs of a patient for the purpose of screening for, preventing,
			 diagnosing, managing or treating an illness, injury or condition or symptoms of
			 an illness, injury or condition;
(ii) Are clinically appropriate in terms of
			 type, frequency, extent, site and duration; and
(iii) Are not primarily for the economic
			 benefit of an insurer or payer or for the convenience of a patient, treating
			 physician or other health care provider.
(c) "Valid, evidence-based sources" includes
			 but is not limited to:
(A) Peer-reviewed
			 scientific studies and medical literature;
(B) Recommendations of nonprofit health care
			 provider professional associations, and;
(C) Specialty societies.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1406 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in ORS
			 743.874 and
			 743.876, "provider" means a
			 person licensed, certified or otherwise authorized or permitted by laws of this
			 state to administer medical or mental health services in the practice of a
			 profession.
(2) As used in ORS
			 743.876, for the purpose of an
			 insurer's procedure for providing an estimate of an enrollee's costs for a
			 covered out-of-network procedure or service:
(a) The "allowable charge" for a covered
			 procedure or service is the estimated amount established under the insurance
			 policy, whether expressed as an "allowable charge," "allowable expense,"
			 "eligible fee" or other term denoting the amount on which the benefit is
			 calculated.
(b) The "billed charge"
			 is the estimated amount charged by a provider for performance of a procedure or
			 service.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1407 - Prohibited Exclusions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 insurer may not deny benefits for a medically necessary treatment or service
			 for a behavioral health condition based solely upon:
(a) The enrollee's interruption of or failure
			 to complete a prior course of treatment;
(b) The insurer's categorical exclusion of
			 such treatment or service when applied to a class of behavioral health
			 conditions; or
(c) The fact that a
			 court ordered the enrollee to receive or obtain the treatment or service for a
			 behavioral health condition, unless otherwise allowed by law.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1408 - Required Disclosures

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Insurers must provide an enrollee or an enrollee's authorized representative
			 reasonable access to and copies of all documents, records, and other
			 information relevant to an enrollee's claim or request for coverage.
(2) Insurers must provide the criteria,
			 guidelines, processes, standards and other factors used to conduct medical
			 necessity, utilization or other clinical reviews for behavioral health
			 conditions. This information must be made available free of charge by the
			 insurer to any current or potential enrollee, beneficiary, or contracting
			 provider upon request, within a reasonable time and in a manner that provides
			 reasonable access to the requestor.
(3) Compliance with these disclosure
			 requirements is not determinative of compliance with any other provisions of
			 applicable federal or state law.
Statutory/Other Authority: ORS
				  731.244 & ORS
				  743A.168
Statutes/Other Implemented: ORS
				  743A.168
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1410 - Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer
			 shall allocate covered procedures or services to the categories established in
			 ORS 743.874(3) and
			 743.876(3) in a
			 manner that will enable the insurer to provide a reasonable estimate of an
			 enrollee's share of costs for a procedure or service. An insurer shall
			 determine its allocation according to its Oregon block of business at least
			 once every 12 months to ensure that the procedures and services are currently
			 the most common procedures in the categories.
(2) When an insurer must provide to an
			 enrollee a combined estimate for two or more procedures or services, the
			 insurer shall apply its standard method of payment to arrive at the combined
			 estimate or other payment method that will achieve an accurate estimate. The
			 insurer must disclose to the enrollee, along with an estimate under this
			 section, that the estimate includes the costs of two or more procedures or
			 services.
(3) An insurer shall
			 disclose with an estimate whether the estimate applies only to those costs
			 specifically relating to the procedure or service, such as is given in commonly
			 used procedure codes, or applies to an episode of care that includes the
			 procedure or service and its related costs.
(4) An insurer shall file with the Director,
			 as required by the Director, the following information for the purpose of
			 assessing the effect of the disclosure requirements in ORS
			 743.874 and
			 743.876:
(a) The number of requests for estimates
			 under ORS 743.874 and
			 743.876, received by the insurer
			 in a calendar year; and
(b) Of the
			 requests in paragraph (a) of this subsection, the number of requests for
			 in-network procedures and services and the number of requests for
			 out-of-network procedures.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1415 - Instructions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer
			 shall make available to enrollees, by online access and by telephone, detailed
			 instructions for obtaining estimates and benefit information under ORS
			 743.874 and
			 743.876. The instructions must
			 do at least the following:
(a) Specify the
			 information needed by the insurer to provide the estimate, including but not
			 limited to information for identifying the procedure or service and the
			 provider.
(b) Describe how an
			 enrollee may obtain an estimate and find benefit information for an in-network
			 procedure, and inform the enrollee that an estimate is not required by law to
			 be provided for a procedure or service that is not included in the insurer's
			 categories; and
(c) Must provide a
			 general explanation for obtaining an estimate for an out-of-network procedure
			 or service and must specify what information is needed for the most accurate
			 estimates.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1420 - Purpose and statutory authority

Current through Register Vol. 63, No. 7, July 1, 2024
The purpose of OAR 836-053-1420  to 836-053-1430  is to establish
				the form and manner for carriers offering individual and group health benefit
				plans to report on behavioral health benefits.
Statutory/Other Authority: Or Laws 2021, ch 629
Statutes/Other Implemented: Or Laws 2021, ch
				  629
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1425 - Definitions for behavioral health benefits reporting

Current through Register Vol. 63, No. 7, July 1, 2024
As used in these rules:
(1) "Behavioral health benefits" means
			 insurance coverage of mental health treatment and services and substance use
			 disorder treatment and services.
(2) "Geographic region" means the regions
			 identified as the specific geographic divisions for Oregon's individual and
			 small group market as required by OAR
			 836-053-0465.
(3) "Incentive payment" means any
			 compensation arrangement, including but not limited to coordination fees,
			 withholds, bonuses, capitation, or any other compensation, to pay a provider or
			 provider group directly or indirectly.
(4) "Median maximum allowable reimbursement
			 rate" means the median of all maximum allowable reimbursement rates, minus
			 incentive payments, paid for each billing code for each provider type during a
			 calendar year.
(5) "Partial denial"
			 means the denial and non-reimbursement of portions of a medical claim submitted
			 for services or supplies provided to a covered enrollee as specified in the
			 plan documents.
(6) "Time-based
			 office visit" means an in-person office or telehealth visit between a health
			 care provider and a patient in specific increments as determined by the
			 relevant CPT billing code.
Statutory/Other Authority: Or Laws 2021, ch 629
Statutes/Other Implemented: Or Laws 2021, ch
				  629