Chapter 735 — Chapter 735
172 sections in this chapter.
ORS 735.542 Pharmacy claims audits; requirements. An entity that audits claims or an independent third party that contracts with an entity to audit claims
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(1) Must establish, in writing, a procedure for a pharmacy to appeal the entity’s findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy’s claims; (2) Must subm…
ORS 735.544 Pharmacy claims audits; standards for review of claims. An entity’s finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions or refills for similar drugs. [2013 c.570 §6]
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Note: See note under 735.530.
ORS 735.546 Pharmacy claims audits; auditors. An entity that contracts with an independent third party to conduct audits may not
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(1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or (2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject to the audit or the holder of the policy or certificate o…
ORS 735.548 Pharmacy claims audits; validation of claims. For purposes of ORS 735.540 to 735.552, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim
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(1) An electronic or physical copy of a prescription that complies with ORS chapter 689 if the prescribed drug was, within 14 days of the dispensing date: (a) Picked up by the patient or the patient’s designee; (b) Delivered by the pharmacy to the patient; or (c) Sent by the phar…
ORS 735.550 Pharmacy claims audits; reports of findings; opportunity to resubmit claim and to contest finding. (1)(a) After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than 45 days after the date on which the audit was completed and must be sent
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(A) By mail or common carrier with a return receipt requested; or (B) Electronically with electronic receipt confirmation. (b) An entity shall provide a pharmacy receiving a preliminary report under this subsection no fewer than 45 days after receiving the report to contest the r…
ORS 735.552 Pharmacy claims audits; exception for fraud. ORS 735.540 to 735.552 do not
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(1) Preclude an entity from instituting an action for fraud against a pharmacy; (2) Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is evidenced by physical review, review of claims data or statements or other investigative meth…
ORS 735.600 [1987 c.838 §2; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.601 [2016 c.94 §1; 2021 c.569 §9; renumbered 413.610 in 2021]
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[Repealed or reserved.]
ORS 735.604 [2016 c.94 §2; renumbered 413.611 in 2021]
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[Repealed or reserved.]
ORS 735.605 [1987 c.838 §3; 1989 c.838 §6; 2003 c.33 §4; 2005 c.634 §4; 2009 c.695 §1; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.608 [2016 c.94 §3; 2021 c.569 §10; renumbered 413.612 in 2021]
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[Repealed or reserved.]
ORS 735.610 [1987 c.838 §4; 1989 c.838 §7; 1993 c.744 §190; 1995 c.79 §361; 2001 c.356 §1; 2003 c.364 §95; 2009 c.595 §1118; 2009 c.828 §71; 2011 c.70 §19; 2013 c.698 §6; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.611 [2016 c.94 §4; repealed by 2021 c.569 §41]
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[Repealed or reserved.]
ORS 735.612 [1989 c.838 §§2,3; 1993 c.744 §191; 2009 c.595 §1119; 2013 c.698 §14; 2014 c.80 §1; 2017 c.477 §5; repealed by 2017 c.477 §6]
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[Repealed or reserved.]
ORS 735.614 [1989 c.838 §4; 1991 c.333 §1; 1995 c.603 §28; 2005 c.304 §1; 2005 c.635 §1; 2009 c.595 §1120; 2009 c.695 §3; 2011 c.131 §1; repealed by 2013 c.698 §42 and 2013 c.640 §20]
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[Repealed or reserved.]
ORS 735.615 [1987 c.838 §5; 1989 c.838 §11; 1993 c.130 §1; 1993 c.212 §1; 1999 c.754 §1; 2005 c.305 §§1,3; 2005 c.634 §1; 2005 c.635 §§2,3; 2009 c.695 §4; 2011 c.70 §20; 2011 c.602 §57; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.616 [Formerly 743.763; 1999 c.987 §1; 2001 c.356 §2; 2009 c.695 §5; 2013 c.698 §15; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.617 [2016 c.94 §5; 2021 c.569 §11; renumbered 413.613 in 2021]
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[Repealed or reserved.]
ORS 735.620 [1987 c.838 §6; 1989 c.838 §12; 2005 c.635 §4; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.625 [1987 c.838 §8; 1989 c.838 §13; 1993 c.130 §2; 1995 c.603 §27; 1999 c.987 §2; 2001 c.356 §3; 2003 c.684 §5; 2005 c.634 §2; 2005 c.635 §5a; 2009 c.595 §1120a; 2013 c.688 §93; 2013 c.698 §16; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.630 [1987 c.838 §9; 1989 c.838 §14; 2009 c.595 §1121; 2013 c.698 §7; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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DISCOUNT MEDICAL PLANS
ORS 735.631 Definitions for ORS 735.631 to 735.643. As used in ORS 735.631 to 735.643
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(1) “Discount medical plan” means a contract, agreement or other business arrangement between a discount medical plan organization and a plan member in which the organization, in exchange for fees, service or subscription charges, dues or other consideration, offers or purports t…
ORS 735.632 License requirement for conducting business as discount medical plan organization. (1) A person may not conduct business as or purport to conduct business as a discount medical plan organization unless the person first obtains a license to operate as a discount medical plan organization from the Director of the Department of Consumer and Business Services in accordance with ORS 735.634
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(2) The license requirement set forth in subsection (1) of this section does not apply to an insurer that offers a discount medical plan. [Formerly 742.422] Note: See note under 735.631.
ORS 735.633 Requirement for contract with provider; contents of contract; retention of record. (1) A discount medical plan organization shall have a written contract or other written agreement with all providers or provider networks that the organization includes or purports to include in a discount medical plan, or with an entity that contracts with or enters into an agreement with a provider network on the organization’s behalf
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(2) The contract or other agreement between a discount medical plan organization and a provider must include: (a) A list of the medical and ancillary services included in the discount medical plan; (b) The provider’s discount rate or rates or a schedule that reflects the provider…
ORS 735.634 License application; investigation; issuance; grounds for denial. (1) Each applicant for a license to operate as a discount medical plan organization shall apply to the Director of the Department of Consumer and Business Services in a form and manner that the director prescribes by rule. An application for a license under this section must contain all of the following
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(a) The applicant’s name, fictitious name, assumed business name and any other identity the applicant uses in conducting business. (b) The applicant’s business address, mailing address, electronic mail address and the Internet address of any website the applicant maintains for pu…
ORS 735.635 [1987 c.838 §10; 1989 c.838 §15; 2013 c.698 §8; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.636 Duties of licensee. A licensee shall
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(1) Notify the Director of the Department of Consumer and Business Services immediately whenever the licensee’s license or other form of authority to operate as a discount medical plan organization in another jurisdiction is suspended, revoked or not renewed in that jurisdiction.…
ORS 735.637 License term; renewal; rules. A license obtained under ORS 735.634 is effective for one year, or for a longer period if the Director of the Department of Consumer and Business Services so prescribes by rule. The director shall prescribe by rule conditions and procedures under which a licensee may renew a license that has expired. [Formerly 742.430]
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Note: See note under 735.631.
ORS 735.638 Duties of discount medical plan organization. A discount medical plan organization shall establish or provide, in connection with every discount medical plan
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(1) A 30-day period in which new plan members may review the discount medical plan and decide whether to continue or to cancel the plan for any reason. The discount medical plan organization shall provide to a member who cancels a discount medical plan within the 30-day period a …
ORS 735.639 Prohibited activities. (1) A person may not use or disseminate in marketing, advertising, promotional, sales or plan documents or other informational materials for discount medical plans or in communications with plan members or prospective plan members
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(a) Misleading, deceptive or false statements; or (b) The terms “health plan,” “coverage,” “copay,” “copayments,” “deductible,” “preexisting condition,” “guaranteed issue,” “premium,” “preferred provider organization” or other terms in a manner that could reasonably mislead an in…
ORS 735.640 [1987 c.838 §12; 1989 c.838 §16; repealed by 2013 c.698 §42 and 2013 c.640 §20]
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[Repealed or reserved.]
ORS 735.641 Investigative powers of director; expenses. The Director of the Department of Consumer and Business Services may investigate a person operating or purporting to operate as a discount medical plan organization and may require the person at any time to produce marketing, promotional and advertising materials, records, books, files or other information the person uses in conducting business as a discount medical plan organization. During an investigation, the person shall respond to the director’s inquiries promptly and truthfully and in the manner or form the director requires. The person subject to an investigation under this section shall pay the expenses incurred in conducting the investigation. [Formerly 742.436]
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Note: See note under 735.631.
ORS 735.642 License suspension, revocation or failure to renew; grounds; effect. (1) The Director of the Department of Consumer and Business Services by order may suspend, revoke or refuse to renew a license issued under ORS 735.634 if the director finds in writing that
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(a) Any fact or condition exists that, if the fact or condition had existed at the time the licensee applied for a license to operate as a discount medical plan organization, would have been grounds for the director to deny a license to the licensee; (b) The licensee has not comp…
ORS 735.643 Injunction; damages; venue; time for commencing action. (1) A person, a municipal or other public corporation or, at the request of the Director of the Department of Consumer and Business Services, the Attorney General may bring an action in a circuit court of this state against a person that operates or purports to operate as a discount medical plan organization but that has not obtained a license under ORS 735.634, to
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(a) Enjoin the person from operating or purporting to operate as a discount medical plan organization or from violating ORS 735.638 or 735.639 or any rule adopted thereunder; or (b) Recover actual damages or statutory damages under this section that arise from the person’s violat…
ORS 735.645 [1987 c.838 §13; 1989 c.838 §17; 1993 c.130 §3; 2005 c.22 §489; 2005 c.634 §3; 2013 c.698 §17; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.650 [1987 c.838 §14; 1989 c.701 §72; 1989 c.838 §18; 1999 c.987 §3; 2001 c.356 §4; 2003 c.87 §20; 2013 c.698 §18; repealed by 2013 c.698 §42, 2013 c.640 §20 and 2017 c.477 §4]
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[Repealed or reserved.]
ORS 735.700 [Formerly 653.705; 2003 c.742 §§1,6; 2005 c.238 §§1,2; 2005 c.262 §§1,2; 2005 c.727 §§1,2; 2005 c.744 §§14,15; 2011 c.70 §23; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.701 [2005 c.744 §2; 2009 c.595 §1123; 2009 c.867 §49; 2013 c.365 §5; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.702 [Formerly 653.715; 2003 c.364 §96; 2003 c.742 §§2,7; 2005 c.744 §§16,17; 2011 c.70 §24; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.703 [2005 c.744 §3; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.704 [Formerly 653.725; repealed by 2005 c.744 §41]
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[Repealed or reserved.]
ORS 735.705 [2005 c.744 §4; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.706 [2001 c.716 §16; 2005 c.744 §18; 2009 c.595 §1124; repealed by 2009 c.595 §1204]
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[Repealed or reserved.]
ORS 735.707 [2005 c.744 §5; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.708 [Formerly 653.735; repealed by 2005 c.744 §41]
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[Repealed or reserved.]
ORS 735.709 [2005 c.744 §10; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.710 [Formerly 653.745; 2003 c.742 §§3,8; 2005 c.238 §§3,4; 2005 c.262 §§3,4; 2005 c.727 §§3,4; 2005 c.744 §§19,20; 2011 c.70 §25; 2013 c.365 §6; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.711 [2007 c.619 §3; repealed by 2011 c.720 §228]
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[Repealed or reserved.]
ORS 735.712 [Formerly 653.747; 2005 c.744 §21; repealed by 2013 c.681 §65 and 2013 c.640 §21]
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[Repealed or reserved.]
ORS 735.714 [2003 c.742 §12; 2005 c.744 §22; repealed by 2011 c.70 §26]
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[Repealed or reserved.]