Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 75 - THIRD PARTY ADMINISTRATORS › Section 836-075-0050 - Exemptions from Third Party Administrator License Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule is
			 adopted under the authority of ORS
			 731.244 and
			 744.704 for the purpose of
			 establishing exemptions under and implementing ORS
			 744.704(1)(p).
			 The persons described in this rule are exempt from the licensing requirement
			 for third party administrators in ORS
			 744.702 and from all other
			 provisions of ORS 744.700 to
			 744.740.
(2) The Department of Human Resources and any
			 organization contracting with the Department of Human Resources for that
			 portion of its business covered under a contract with the Department are
			 exempt.
(3) A health care provider
			 that contracts with an insurer to provide health care services to insurance
			 plan enrollees and is compensated for such services on a prepaid, capitated or
			 similar basis is exempt when the insurer and the provider operate under a
			 written agreement that includes all of the conditions specified in this
			 section. For the purpose of this section, a "health care provider" or
			 "provider" means a licensed health care practitioner or a group of such
			 practitioners, a licensed health care facility or group of such facilities and
			 any similar health care organization. The conditions required to be included in
			 the agreement are as follows:
(a) The primary
			 contractual responsibility of the provider is the delivery of health care
			 services to insurance plan enrollees and the administrative duties performed by
			 the provider for the insurer are in support of the delivery of health care
			 services;
(b) The administrative
			 duties performed by the provider for the insurer are limited to the adjusting
			 or settling of claims for insurance plan enrollees and the insurer retains
			 responsibility for providing competent administration of its
			 programs;
(c) The insurer performs
			 all functions that pertain to soliciting and effecting coverage, underwriting,
			 collecting premiums, determining plan benefits, determining premium rates and
			 securing any reinsurance for the insurer's obligations;
(d) The rules pertaining to the adjusting or
			 settling of claims are provided in writing by the insurer to the
			 provider;
(e) The insurer at least
			 annually conducts a review of the claims-related activities performed by the
			 provider for the insurer to ensure that those operations are in compliance with
			 subsection (b) of this section;
(f)
			 The provider allows the insurer access to the administrative books and records
			 of the provider that document the claims-related activities performed for the
			 insurer for the purpose of assuring the proper administration of claims, and
			 the insurer agrees to make those books and records available for examination by
			 the Director in accordance with ORS
			 731.300,
			 731.304 and
			 731.308;
(g) The provider allows the insurer access to
			 the relevant financial books and records of the provider that will enable the
			 insurer to determine the financial ability of the provider to fulfill its
			 responsibilities under the agreement, and both parties assure that
			 confidentiality of financial and patient records is maintained in accordance
			 with applicable federal and state requirements;
(h) The insurer makes certain that the
			 administrative books and records of the provider that document the
			 claims-related activities performed for the insurer are maintained by the
			 provider in accordance with prudent standards of insurance record-keeping and
			 that such books and records are maintained by the provider for a period of not
			 less than five years from the date of their creation; and
(i) The conditions applicable to the provider
			 in subsections (f) and (h) of this section must not be terminated upon a
			 termination of the agreement, whether by rescission or otherwise.