Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1340 - Timelines and Notice for Dispute That is Not Expedited

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer shall give the director of the
			 Department of Consumer and Business Services notice of an enrollee's request
			 for independent review by delivering a copy of the request to the director not
			 later than the second business day of the insurer after the insurer receives
			 the request for the independent review. In the event the enrollee applies to
			 the director rather than to the insurer for independent review, the director
			 shall provide the insurer notice of the enrollee's request for independent
			 review by delivering a copy of the request to the insurer not later than the
			 next business day of the department after the director receives the request for
			 independent review.
(2) If an
			 insurer reverses its final adverse determination before expiration of the
			 deadline for sending the notice to the director under section 1 of this rule,
			 the insurer must notify the enrollee not later than the next business day of
			 the insurer after the insurer's reversal. The notice to the enrollee may be
			 given by electronic mail, facsimile or by telephone, followed by a written
			 confirmation within two business days of the insurer.
(3) Not later than the next business day of
			 the department after the director has received a request for independent review
			 from an insurer or an enrollee, the director shall assign the review to one of
			 the independent review organizations with whom the director has contracted. The
			 director shall notify the insurer in writing of the name and address of the
			 independent review organization to which the request for the independent review
			 should be sent. If sending written notice will unduly delay notification, the
			 director shall give the notice by electronic mail, facsimile or by telephone,
			 followed by a written confirmation within two business days of the
			 department.
(4) The director shall
			 notify the enrollee of the assignment of the request, not later than the second
			 business day of the department after the director gave notice under section 3
			 of this rule. The notice must include a written description of the independent
			 review organization selected to conduct the independent review and information
			 explaining how the enrollee may provide the director with documentation
			 regarding any potential conflict of interest of the independent review
			 organization as described in OAR 836-053-1320.
(5) Not later than the third calendar day
			 following receipt of notice from the director under section 4 of this rule, or
			 the subsequent business day of the department if any of the days is not a
			 normal business day of the department, the enrollee may provide the director
			 with documentation in writing regarding a potential conflict of interest of the
			 independent review organization. If sending written documentation will unduly
			 delay the process, the enrollee shall give the notice by electronic mail,
			 facsimile or by telephone, followed by a written confirmation within two
			 business days of the department. If the director determines that the
			 independent review organization presents a conflict of interest as described in
			 OAR 836-053-1320, the director shall assign another independent review
			 organization not later than the next business day of the department. The
			 director shall notify the insurer of the new independent review organization to
			 which the request for the independent review should be sent. The director shall
			 also notify the enrollee of the director's determination regarding the
			 potential conflict of interest and the name and address of the new independent
			 review organization.
(6) Not later
			 than the fifth business day of the insurer after the date on which the insurer
			 received notice from the director under section 3 of this rule, the insurer
			 shall deliver to the assigned independent review organization the following
			 documents and information considered in making the insurer's final adverse
			 decision, including the following:
(a)
			 Information submitted to the insurer by a provider or the enrollee in support
			 of the request for coverage under the health benefit plan's
			 procedures.
(b) Information used by
			 the health benefit plan during the internal appeal process to determine whether
			 the course or plan of treatment is:
(A)
			 Medically necessary;
(B)
			 Experimental or investigational; or
(C) An active course of treatment for
			 purposes of continuity of care.
(c) A copy of all denial letters issued by
			 the plan concerning the case under review.
(d) An index of all submitted
			 documents.