Title 56, Insurance
17 chapters · 1,565 sections in this title.
ORS 735.546 Pharmacy claims audits; auditors
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An entity that contracts with an independent third party to conduct audits may not: (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 en…
ORS 735.548 Pharmacy claims audits; validation of claims
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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: (1) An electronic or physical copy of a prescription that complies with ORS chapter 689 if the prescr…
ORS 735.550 Pharmacy claims audits; reports of findings; opportunity to resubmit claim and to contest finding
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(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…
ORS 735.552 Pharmacy claims audits; exception for fraud
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ORS 735.540 to 735.552 do not: (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 stateme…
ORS 735.631 Definitions for ORS 735.631 to 735.643
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As used in ORS 735.631 to 735.643: (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 …
ORS 735.632 License requirement for conducting business as discount medical plan organization
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(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 ac…
ORS 735.633 Requirement for contract with provider; contents of contract; retention of record
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(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 agre…
ORS 735.634 License application; investigation; issuance; grounds for denial
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(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 cont…
ORS 735.636 Duties of licensee
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A licensee shall: (1) Notify the Director of the Department of Consumer and Business Services immediately whenever the licensees license or other form of authority to operate as a discount medical plan organization in another jurisdiction is suspended, revoked or not renewed in …
ORS 735.637 License term; renewal; rules
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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 lice…
ORS 735.638 Duties of discount medical plan organization
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A discount medical plan organization shall establish or provide, in connection with every discount medical plan: (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 me…
ORS 735.639 Prohibited activities
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(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: (a) Misleading, deceptive or false statements; o…
ORS 735.641 Investigative powers of director; expenses
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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,…
ORS 735.642 License suspension, revocation or failure to renew; grounds; effect
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(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: (a) Any fact or condition exists that, if the fact or condition had existed at the time t…
ORS 735.643 Injunction; damages; venue; time for commencing action
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(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 disco…