Chapter 743B — Chapter 743B
107 sections in this chapter.
ORS 743B.287 Balance billing prohibited for health care facility services. (1) As used in this section
3.1K chars
(a) “Emergency services” has the meaning given that term in ORS 743A.012. (b) “Enrollee” means: (A) An individual who is enrolled in a health benefit plan or a covered dependent or beneficiary of the individual; or (B) A subscriber to a health care service contract or a covered d…
ORS 743B.288 Balance billing prohibited for labor and delivery services rendered by out-of-network provider to which insured was diverted during public health emergency. (1) As used in this section
1.6K chars
(a) “In-network provider” means an individual or facility that contracts with a health benefit plan or health care service contractor to provide health care services to an individual insured under the health benefit plan or health care service contract. (b) “Out-of-network provid…
ORS 743B.290 Hospital payment of copayment or deductible for insured patient. An insurer offering a policy or certificate of health insurance may not prohibit a hospital, as a condition of reimbursing a claim for hospital services, from paying or waiving all or a portion of a copayment or deductible owed by an insured under the policy or certificate. [2019 c.497 §9]
0.2K chars
Note: 743B.290 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
ORS 743B.292 Balance billing prohibited for ground ambulance services; health benefit plan reimbursement rate requirements; reporting and database of established local rate; rules; penalties. (1) As used in this section
5.2K chars
(a) “Enrollee” has the meaning given that term in ORS 743B.005. (b) “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that includes an analysis of the …
ORS 743B.300 Disclosure of differences in replacement health insurance policies; nonduplication for persons 65 and older; rules. (1) The Director of the Department of Consumer and Business Services shall adopt by rule requirements for disclosure by group and individual health insurers to individual and group health insurance policyholders the difference between coverage under the existing policy and coverage being offered to replace that coverage
0.5K chars
(2) The provisions of this section do not apply to disability income insurance. (3) The director shall adopt by rule requirements for nonduplication and replacement of major medical, Medicare supplement, long term care and special illness policies for applicants 65 years of age a…
ORS 743B.310 Rescinding coverage; permissible bases; notice; rules. (1) As used in this section, “rescind” means to retroactively cancel or discontinue coverage under a health benefit plan or group or individual health insurance policy for reasons other than failure to timely pay required premiums or required contributions toward the cost of coverage
1.6K chars
(2) An insurer may not rescind coverage of an individual under a health benefit plan or group or individual health insurance policy unless: (a) The individual or a person seeking coverage on behalf of the individual: (A) Performs an act, practice or omission that constitutes frau…
ORS 743B.320 Minimum grace period; notice upon termination of policy; effect of failure to notify. (1) A group health insurance policy shall contain a provision allowing a minimum grace period of 10 days after the premium due date for payment of premium
2.2K chars
(2) An insurer of a group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, that seeks to terminate a policy for nonpayment of premium shall notify the policyholder as describe…
ORS 743B.321 Applicability of ORS 743B.320. ORS 743B.320 applies to multiple employer trusts when an employer ceases to participate therein. [Formerly 743.562]
0.0K chars
[Repealed or reserved.]
ORS 743B.323 Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium; rules. (1) Before a health insurer selling an individual policy or group health benefit plan may cancel a policy for nonpayment of premium, the insurer must mail a separate notice to the policyholder informing the policyholder that the premium was not received and that the policy will be terminated as of the premium due date if the premium is not received by the end of the applicable grace period required by ORS 743.417 and 743B.320
0.6K chars
(2) The notice described in subsection (1) of this section shall be in writing and mailed by first class mail to the last-known address of the policyholder at least: (a) Ten days prior to the end of the grace period specified in ORS 743.417 (1)(a) and 743B.320; or (b) Fifteen day…
ORS 743B.324 Rules for certain notice requirements. The Director of the Department of Consumer and Business Services shall adopt rules necessary for the implementation and administration of ORS 743B.323 and the amendments to ORS 743.417, 743.420, 743B.013, 743B.105, 743B.125 and 743B.320 by sections 9 to 14, chapter 943, Oregon Laws 2001. [Formerly 743.566]
0.2K chars
Note: 743B.324 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743B or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
ORS 743B.330 Notice to policyholder required for cancellation or nonrenewal of health benefit plan; effect of failure to give notice. (1) As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005
2.4K chars
(2) An insurer shall notify a policyholder in writing if the insurer cancels or does not renew the policyholder’s individual health benefit plan. The notice shall be sent to the policyholder’s last-known mailing address by first class mail in a specially marked envelope or, if th…
ORS 743B.340 When group health insurance policies to continue in effect upon payment of premium by insured individual. (1) Every group health insurance policy delivered or issued for delivery in this state shall contain in substance the following provisions, applicable to the coverage for hospital or medical services or expenses provided under the policy
5.0K chars
(a) A provision that, when the premium for the policy or any part thereof is paid by an employer under the terms of a collective bargaining agreement, if there is a cessation of work by employees insured under the policy due to a strike or lockout, the policy, upon timely payment…
ORS 743B.341 Continuation of benefits after termination of group health insurance policy; rules. (1) Every group health insurance policy that provides coverage for hospital or medical services or expenses shall provide that the insurer shall continue its obligation for benefits under the policy for any person insured under the policy who is hospitalized on the date of termination if the policy is terminated and immediately replaced by a group health insurance policy issued by another insurer. Any payment required under this section is subject to all terms, limitations and conditions of the policy except those relating to termination of benefits. Any obligation by an insurer under this section continues until the hospital confinement ends or hospital benefits under the policy are exhausted, whichever is earlier
0.4K chars
(2) The Director of the Department of Consumer and Business Services may adopt rules providing for uninterrupted coverage for individuals insured under a group health insurance policy providing coverage for hospital or medical expenses, when such a policy is replaced by a policy …
ORS 743B.342 Continuation of benefits after injury or illness covered by workers’ compensation. Every policy of group health insurance delivered or issued for delivery in this state shall contain a provision applicable to the coverage for hospital or medical services or expenses provided under the policy that if an employee incurs an injury or illness for which a workers’ compensation claim is filed, that policy will continue in effect with respect to that employee upon timely payment by the employee of the premium that includes the individual contribution and the contribution due from the employer under the applicable benefit plan. The employee may maintain such coverage until whichever of the following events first occurs
0.2K chars
(1) The employee takes full-time employment with another employer; or (2) Six months from the date that the employee first makes payment under this section. [Formerly 743.530]
ORS 743B.343 Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older. (1) A group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall contain a provision that
1.2K chars
(a) The surviving spouse of a certificate holder may continue coverage under the policy, at the death of the certificate holder, with respect to the spouse and any dependent children whose coverage under the policy otherwise would terminate because of the death of the certificate…
ORS 743B.344 Procedure for obtaining continuation of coverage under ORS 743B.343. (1) As used in subsections (1) to (6) of this section, “plan administrator” means
2.3K chars
(a) The person designated as the plan administrator by the instrument under which the group health insurance plan is operated; or (b) If no plan administrator is designated, the plan sponsor. (2) Within 60 days of legal separation or the entry of a judgment of dissolution of marr…
ORS 743B.345 Premium for continuation of coverage under ORS 743B.344; termination of right to continuation. If a legally separated, divorced or surviving spouse elects continuation of coverage under ORS 743B.344 (1) to (6)
1.5K chars
(1) The monthly premium for the continuation shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group plan plus the amount that the group policyholder would contribute toward t…
ORS 743B.347 Continuation of coverage under group policy upon termination of membership in group health insurance policy; applicability of waiting period to rehired employee. (1) As used in this section
5.9K chars
(a) “Covered person” means an individual who was a certificate holder under a group health insurance policy: (A) On the day before a qualifying event; and (B) During the three-month period ending on the date of the qualifying event. (b) “Qualified beneficiary” means: (A) A spouse…
ORS 743B.400 Decisions regarding health care facility length of stay, level of care and follow-up care. (1) All clinical decisions regarding length of stay in a health care facility as defined in ORS 442.015, transfer between levels of care and follow-up care shall be the decision of the treating provider in consultation with the patient, as appropriate
0.2K chars
(2) An insurer may not terminate or restrict the practice privileges of any provider solely on the basis of one or more decisions made pursuant to subsection (1) of this section. [Formerly 743.829]
ORS 743B.403 Insurer prohibited practices; patient communication and referral. No insurer may terminate or otherwise financially penalize a provider for
1.0K chars
(1) Providing information to or communicating with a patient in a manner that is not slanderous, defamatory or intentionally inaccurate concerning: (a) Any aspect of the patient’s medical condition; (b) Any proposed treatment or treatment alternatives, whether covered by the insu…
ORS 743B.405 Medical services contract provisions; nonprovider party prohibitions; future contracts. (1) A medical services contract may not require the provider, as an element of the contract or as a condition of compensation for services, to agree
5.8K chars
(a) In the event of alleged improper medical treatment of a patient, to indemnify the other party to the medical services contract for any damages, awards or liabilities including but not limited to judgments, settlements, attorney fees, court costs and any associated charges inc…
ORS 743B.406 Vision care providers. (1) As used in this section
2.9K chars
(a) “Contractual discount” means a percentage reduction, required under a contract with an insurer, in a vision care provider’s usual and customary rate for vision care services and materials. (b) “Discount card” means a card or other purchasing mechanism or device that is not in…
ORS 743B.407 Naturopathic physicians. (1) An insurer shall provide a naturopathic physician the choice of applying to be credentialed by the insurer as a primary care provider or as a specialty care provider
0.4K chars
(2) To be credentialed by an insurer as a primary care provider, a naturopathic physician must meet the credentialing requirements as established by the insurer. [2015 c.224 §2] Note: 743B.407 was added to and made a part of the Insurance Code by legislative action but was not ad…
ORS 743B.420 Prior authorization requirements. Except in the case of misrepresentation, prior authorization determinations shall be subject to the following requirements
0.4K chars
(1) Prior authorization determinations relating to benefit coverage and medical necessity shall be binding on the insurer if obtained no more than 60 days prior to the date the service is provided. (2) Prior authorization determinations relating to enrollee eligibility shall be b…
ORS 743B.422 Utilization review requirements for medical services contracts to which insurer not party; right to appeal. All utilization review performed pursuant to a medical services contract to which an insurer is not a party shall comply with the following
1.9K chars
(1) The criteria used in the review process and the method of development of the criteria shall be made available for review to a party to such medical services contract upon request. (2) A physician licensed under ORS 677.100 to 677.228 shall be responsible for all final recomme…
ORS 743B.423 Utilization review requirements for insurers offering health benefit plan. (1) All insurers offering a health benefit plan in this state that provide utilization review or have utilization review provided on their behalf shall file an annual summary with the Department of Consumer and Business Services that describes all utilization review policies, including delegated utilization review functions, and documents the insurer’s procedures for monitoring of utilization review activities
6.6K chars
(2) All utilization review activities conducted pursuant to subsection (1) of this section shall comply with the following: (a) In addition to the requirements of ORS 743B.602, in establishing utilization review, the insurer must use clinical review criteria that are evidence-bas…
ORS 743B.424 Applicability. The provisions of ORS 743B.001, 743B.220, 743B.405 and 743B.422 do not apply to medical services contracts for services to be provided under ORS chapter 656. [Formerly 743.811]
0.0K chars
Note: See note under 743B.405.
ORS 743B.425 Prohibited restrictions on coverage of treatment for opioid or opiate withdrawal, post-exposure and preexposure prophylactic antiretroviral drugs and drugs for treatment of human immunodeficiency virus or acquired immunodeficiency syndrome; exceptions. (1) An insurer offering a health benefit plan may not
1.2K chars
(a) Require prior authorization: (A) During the first 60 days of treatment, including medication therapy, prescribed for opioid or opiate withdrawal; or (B) For post-exposure prophylactic antiretroviral drugs or preexposure prophylactic antiretroviral drugs, or drugs prescribed f…
ORS 743B.427 Nonquantitative treatment limitations on coverage of behavioral health conditions; carrier reporting requirements; confidentiality; summary annually reported to legislative committees. (1) As used in this section
7.1K chars
(a) “Behavioral health benefits” means insurance coverage of mental health treatment and services and substance use disorder treatment and services. (b) “Carrier” has the meaning given that term in ORS 743B.005. (c) “Geographic region” means the geographic area of the state estab…
ORS 743B.430 Prohibited restrictions on prior authorization requirements for surgical procedures. An insurer offering a health benefit plan that requires prior authorization for surgical procedures may not require prior authorization for an additional or related health care procedure that is identified during the authorized surgical procedure if
1.1K chars
(1) The provider, while providing an approved surgical procedure, identifies a medical condition, disease or ailment that was not identified in the prior authorization request and, in accordance with generally accepted standards of medical practice, determines that performing a r…
ORS 743B.445 Application programming interface; requirements. (1) An insurer offering a health benefit plan in this state that provides utilization review or has utilization review provided on the insurer’s behalf shall utilize a prior authorization application programming interface as described in 45 C.F.R. 156.223(b), as in effect on February 28, 2024. The application programming interface shall enable a provider to
0.9K chars
(a) Determine whether prior authorization is required; (b) Identify the information and documentation necessary to submit the request; and (c) Transfer prior authorization requests and determinations from the provider’s electronic health records or practice management system thro…
ORS 743B.450 Prompt payment of claims; limits on use of electronic payment methods; rules. (1) Except as provided in this subsection, when a claim under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim. If an insurer requires additional information before payment of a claim, not later than 30 days after the date on which the insurer receives the claim, the insurer shall notify the enrollee and the provider in writing and give the enrollee and the provider an explanation of the additional information needed to process the claim. The insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the additional information
1.6K chars
(2) A contract between an insurer and a provider may not include a provision governing payment of claims that limits the rights and remedies available to a provider under this section and ORS 743B.452 or has the effect of relieving either party of its obligations under this secti…
ORS 743B.451 Refund of paid claims. (1) As used in this section, “refund” means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider
3.3K chars
(2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Reques…
ORS 743B.452 Interest on unpaid claims. (1) An insurer that fails to pay a claim to a provider within the timelines established in ORS 743B.450 shall pay simple interest of 12 percent per annum on the unpaid amount of the claim that is due and owing, accruing from the date after the payment was due until the claim is paid. Interest on any overdue payment for a claim begins to accrue on the 31st day after
0.6K chars
(a) The date on which the insurer received the claim; or (b) The date the insurer receives the requested additional information. (2) The interest is payable with the payment of the claim. An insurer is not required to pay interest that is in the amount of $2 or less on any claim.…
ORS 743B.453 Underpayment of claims. (1) Except in the case of fraud and except as provided in subsection (3) of this section, a health care provider may not
2.2K chars
(a) Request additional payment from a health insurer to satisfy a claim unless the provider: (A) Requests the additional payment in writing on or before the last day of the period specified by the contract or 18 months after the date the claim was denied or payment intended to sa…
ORS 743B.454 Claims submitted during credentialing period. (1) As used in this section
4.1K chars
(a) “Complete application” means a provider’s application to a health insurer to become a credentialed provider that includes: (A) Information required by the health insurer; (B) Proof that the provider is licensed by a health professional regulatory board as defined in ORS 676.1…
ORS 743B.456 Limits on use of electronic payment methods for reimbursement of dental claims. (1) As used in this section, “dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit
1.1K chars
(2) A dental insurer may pay a claim for reimbursement made by a dental care provider using a credit card or electronic funds transfer payment method that imposes on the provider a fee or similar charge to process the payment if: (a) The dental insurer notifies the provider, in a…
ORS 743B.458 Performance-based incentive payments for primary care. An insurer offering a health benefit plan, as defined in ORS 743B.005, that reimburses the costs of services provided by a national primary care medical home payment model, conducted by the Center for Medicare and Medicaid Innovation in accordance with 42 U.S.C. 1315a, that includes performance-based incentive payments for primary care, shall offer similar alternative payment methodologies to reimburse the costs of services provided by patient centered primary care homes identified in accordance with ORS 413.259 that serve beneficiaries of the health benefit plan. [2017 c.489 §7]
0.2K chars
Note: 743B.458 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
ORS 743B.460 Conditions for restricting payments to only in-network providers. (1) An insurer may negotiate and enter into contracts for alternative rates of payment with providers to provide services covered by a group health insurance policy and may offer the benefit of such alternative rates to insureds who select such providers. An insurer may utilize such contracts by offering a choice of plans at the time an insured enrolls, one of which provides benefits only for services by members of a particular provider organization with whom the insurer has an agreement. If an insured chooses such a plan, benefits are payable only for services rendered by a member of that provider organization, unless such services were requested by a member of such organization or are rendered as the result of an emergency
0.5K chars
(2) Benefits paid by an insurer to a provider under subsection (1) of this section shall discharge the insurer’s obligation with respect to the amount of insurance so paid. (3) Insurers shall provide group policyholders with a current roster of institutional and professional prov…
ORS 743B.462 Direct payments to providers. (1) As used in this section
0.9K chars
(a) “Health benefit plan” has the meaning given that term in ORS 743B.005. (b) “Provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services, including substance use disorder services, in t…
ORS 743B.470 Medicaid not considered in coverage eligibility determination; claims for services paid for by medical assistance; prohibited ground for denial of enrollment of child; insurer duties. (1) For the purposes of this section
5.1K chars
(a) “Health insurer” or “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contra…
ORS 743B.475 Guidelines for coordination of benefits; rules. The Director of the Department of Consumer and Business Services shall by rule establish guidelines for the coordination of benefits for individual and group health insurance, including
4.5K chars
(1) The procedures by which persons insured under the policies are to be made aware of the existence of a coordination of benefits provision; (2) The benefits which may be subject to such a provision; (3) The effect of such a provision on the benefits provided; (4) Establishment …
ORS 743B.500 Selling and leasing of provider panels by contracting entity; definitions. As used in this section and ORS 743B.501 to 743B.503
3.9K chars
(1)(a) “Contracting entity” means any person that contracts directly with a provider for the delivery of health care services or contracts with a third party for the purpose of selling or making available to the third party the provider’s health care services or discounted rates …
ORS 743B.501 Registration of contracting entity. (1) A contracting entity that does not have a certificate of authority shall register with the Department of Consumer and Business Services as a contracting entity by submitting the following information to the department in written or electronic form as prescribed by the department along with any fee prescribed by the department
0.8K chars
(a) The official name of the entity and any secondary, alternative or substitute designations. (b) The mailing address and telephone number of the headquarters of the entity. (c) The name and telephone number of a representative of the entity who shall serve as the primary contac…
ORS 743B.502 Third party contracts for leasing of provider panels; requirements. (1) A contracting entity or a third party may not contract with another third party to provide access to the health care services and discounted rates of a provider under a provider network contract unless
3.6K chars
(a) The third party contract is specifically authorized by the provider network contract; and (b) The third party contract obligates the third party to comply with all applicable terms, limitations and conditions of the provider network contract. (2) A contracting entity that pro…
ORS 743B.503 Additional requirements for third party contracts. (1) A contract between a third party and a contracting entity or between two third parties with respect to a provider network contract must comply with this section and ORS 743B.502
1.0K chars
(2)(a) A third party shall inform the contracting entity and providers under a contracting entity’s provider network contract of a website, toll-free number or other readily available mechanism to identify the names of all third parties to which the third party provides access to…
ORS 743B.504 Third party contracts for dental care services. (1) As used in this section
5.2K chars
(a) “Dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit. (b)(A) “Material modification” includes, but is not limited to, changes to the terms or conditions of a contract that alter: (i) Reimburs…
ORS 743B.505 Provider networks; rules. (1) A carrier offering an individual or group health benefit plan in this state that provides coverage through a specified network of health care providers shall
6.6K chars
(a) Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure that all covered services under the health benefit plan, including mental health, substance use disorder and reproductive health care and trea…
ORS 743B.550 Disclosure of information. Nothing in ORS 743.008, 743A.012, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.250, 743B.400, 743B.403, 743B.420, 743B.423 and 743B.550 shall be construed to require disclosure of information that is otherwise privileged or confidential under any other provision of law. [Formerly 743.839; 2021 c.97 §83]
0.0K chars
[Repealed or reserved.]
ORS 743B.555 Confidential communications. (1) As used in this section
4.5K chars
(a) “Carrier” has the meaning given that term in ORS 743B.005. (b) “Communication” includes: (A) An explanation of benefits notice; (B) Information about an appointment; (C) A notice of an adverse benefit determination; (D) A carrier’s or third party administrator’s request for a…