Oregon Administrative Code

836-053-1100 Internal Appeals Process (1) An insurer must acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal. (2)An insurer must make a decision on the appeal not later than the 30th day after receiving notice of the appeal…

836-053-1110 Notice of Complaint Filing with Director A written decision by an insurer in response to a grievance must prominently disclose the following information: (1) That the enrollee has a right to file a complaint or seek other assistance from the Division of Financial Reg…

836-053-1130 Annual Summary, Utilization Review (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 Fi…

836-053-1140 Appeal and Utilization Review Determinations (1) When a provider first appeals an insurer denial described in ORS 743.807(2)(c): (a) The insurer must acknowledge receipt of the notice of appeal not later than the seventh day after receiving the notice; and (b) An app…

836-053-1170 Annual Summary, Quality Assessment Activities (1) To comply with the requirements of ORS 743.814(2) and (3), an insurer offering a managed health benefit plan shall electronically submit on or before June 30 of each calendar year an annual quality assessment program …

836-053-1180 Format and Instructions for Report Required by ORS 743.818 (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 sel…

836-053-1190 Annual Summary, Uniform Indicators of Network Adequacy (1) An insurer offering managed health insurance or preferred provider organization insurance must submit its annual summary required under ORS 743.817 on March 1 of each year. Filing and reporting requirements i…

836-053-1200 Prior Authorization Requirements for Health Benefit Plans (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…

836-053-1203 Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans (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, …

836-053-1205 Uniform Prescription Drug Prior Authorization Request Form (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 …

836-053-1300 Purpose and Scope; Application (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 t…

836-053-1305 Definitions; Authority to Act for Enrollee (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 osteopat…

836-053-1310 Contracting Requirements (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…

836-053-1315 Performance Criteria 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 res…

836-053-1317 Professional Qualifications (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 ma…

836-053-1320 Conflict of Interest (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 t…

836-053-1325 Procedures for Conducting External Reviews (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 …

836-053-1330 Criteria and Considerations for External Review Determinations (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 decisi…

836-053-1335 Procedures for Complaint Investigation (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 comm…

836-053-1337 Preliminary Review by Insurer 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 insur…

836-053-1340 Timelines and Notice for Dispute That is Not Expedited (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…

836-053-1342 Timelines and Notice for Expedited Decision-Making (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 refer…

836-053-1345 Quality Assurance Mechanisms (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, im…

836-053-1350 Ongoing Requirements for Independent Review Organizations (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 review…

836-053-1355 Synopses (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 includ…

836-053-1360 External Review Reporting (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…

836-053-1365 Fees for External Reviews 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 b…

836-053-1400 Format and Instructions for Report Required by ORS 743.748 (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 …

836-053-1403 Definitions of Coordinated Care and Case Management for Behavioral Health Care Services (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…

836-053-1404 Definitions; Noncontracting Providers; Co-Morbidity Disorders (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 Manua…

836-053-1405 General Requirements for Coverage of Behavioral Health Conditions (1) A group health insurance policy or an individual health benefit plan issued or renewed in this state shall provide coverage or reimbursement for medically necessary treatment of behavioral health c…

836-053-1407 Prohibited Exclusions (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 cat…

836-053-1408 Required Disclosures (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 t…

836-053-1409 Definitions (1) As used in ORS 743B.281 and 743B.282, “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 743B.282…

836-053-1410 Procedures (1) An insurer must 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.…

836-053-1415 Instructions (1) An insurer must make available to enrollees detailed instructions by telephone and Internet for obtaining estimates and benefit information under ORS 743.874 and 743.876. At a minimum, the instructions must: (a) Specify the information needed by the …

836-053-1420 Purpose and statutory authority 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 62…

836-053-1425 Definitions for behavioral health benefits reporting 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…

836-053-1430 Form and Manner for Behavioral Health Benefits Reporting (1) An insurer offering individual or group health benefit plans must submit its annual report for behavioral health benefits no later than March 1 of each year. (2) General requirements for reporting and submi…

836-053-1500 Purpose; Statutory Authority; Applicability (1) OAR 836-053-1500 to 836-053-1510 are adopted for the purpose of implementing sections 1 to 4, chapter 575, Oregon Laws 2015 and section 7, chapter 26, Oregon Laws 2016. (2) The requirements set forth in OAR 836-053-1500…

836-053-1505 Definitions for OAR 836-053-1500 to 836-053-1510 As used in OAR 836-053-1500 to 836-053-1510: (1) The definitions set forth in Section 2, chapter 575, Oregon Laws 2015 apply to the use of those terms in these rules. (2) “Prominent carrier” means: (a) A carrier with a…

836-053-1510 Prominent Carrier Reporting Requirements (1) Not later than October 1 of each year from 2016 through 2018, each prominent carrier shall submit to the Department of Consumer and Business Services all non-claims based primary care expenditures for the prior calendar ye…

836-053-1520 Purpose; Statutory Authority; Applicability The requirements set out in OAR 836-053-1520 to 836-053-1530 apply to insurers offering health benefit plans, as defined in ORS 743B.005, that reimburse the costs of services provided by a national primary care medical home…

836-053-1525 Definitions The following definitions apply to OAR 836-053-1520 to 836-053-1530: (1) “APAC Data Reporting Program” means the all payer all claims data reporting program pursuant to ORS 442.464, 442.466, and 442.993. (2) “APM” means alternative payment methodologies. …

836-053-1530 Reporting Requirements (1) No later than September 30 of each year beginning September 30, 2019, an insurer participating in CPC+ shall submit to the Department of Consumer and Business Services the Annual Supplemental Provider Level APM Summary report using the APAC…

836-053-1630 Drug Price Transparency Insurer Reporting (1) For the purposes of this rule, “insurer” means a licensed insurance company, health care services contractor, or health maintenance organization that issues health benefit plans as defined in ORS 743B.005(16) in this stat…

836-054-0000 Election of Lower Limits for Uninsured Motorist Coverage (1) This rule is adopted under the authority of ORS 731.244 for the purpose of implementing ORS 742.502. (2) This rule establishes in Exhibit 1 an example of the form of statement electing lower limits for unin…

836-054-0020 Timely Notice of Denial of Charges to Provider (1) This rule is adopted under the authority of ORS 731.244 for the purpose of implementing ORS 742.524. (2) When an insurer is required to provide notice of a denial of charges within 60 days of receipt, it shall be pre…

836-054-0110 Statutory Authority; Purpose (1) OAR 836-054-0110 to 836-054-0130 are adopted pursuant to the general rulemaking authority of the director of the Department of Consumer and Business Services in ORS 731.244 and the specific authority in ORS 742.075. (2) OAR 836-054-01…

836-054-0115 Definitions As used in OAR 836-054-0110 to 836-054-0130: (1) “Qualified policy” has the meaning set forth in ORS 742.075. (2) “Qualified insurer” means any insurer that offers a qualified policy and whose combined written premium of the qualifying lines is $1,000,000…