(a) Decide whether the dispute pertains to an adverse benefit determination and notify the enrollee and insurer in writing of the decision. If the decision is against the enrollee, the independent review organization shall notify the enrollee of the right to file a complaint with or seek other assistance from the Department of Consumer and Business Services and the availability of other assistance as specified by the department.
(b) Appoint a reviewer or reviewers as determined appropriate by the independent review organization. At least one reviewer must be a clinician in the same or a similar specialty as the provider who prescribed the treatment that is under review.
(c) Notify the enrollee of information that the enrollee is required to provide and any additional information the enrollee may provide, and when the information must be submitted as provided in ORS 743B.252.
(d) Notify the insurer of additional information the independent review organization requires and when the information must be submitted as provided in ORS 743B.252.
(e) Decide the dispute relating to the adverse benefit determination of the insurer and issue the decision in writing.
(2) A decision by an independent review organization shall be based on expert medical judgment after consideration of the enrollee’s medical record, the recommendations of each of the enrollee’s providers, relevant medical, scientific and cost-effectiveness evidence and standards of medical practice in the United States. An independent review organization must make its decision in accordance with the coverage described in the health benefit plan, except that the independent review organization may override the insurer’s standards for medically necessary or experimental or investigational treatment if the independent review organization determines that the standards of the insurer are unreasonable or are inconsistent with sound medical practice.
(3) When review is expedited, the independent review organization shall issue a decision not later than the third day after the date on which the enrollee applies to the insurer for an expedited review or the Director of the Department of Consumer and Business Services orders an expedited review.
(4) When a review is not expedited, the independent review organization shall issue a decision not later than the 30th day after the enrollee applies to the insurer for a review or the director orders a review.
(5) An independent review organization shall file synopses of its decisions with the director according to the format and other requirements established by the director. The synopses shall exclude information that is confidential, that is otherwise exempt from disclosure under ORS 192.345 and 192.355 or that may otherwise allow identification of an enrollee. The director shall make the synopses public. [Formerly 743.862; 2021 c.154 §3]
Structure 2021 Oregon Revised Statutes
Volume : 18 - Financial Institutions, Insurance
Chapter 743B - Health Benefit Plans: Individual and Group
Section 743B.001 - Definitions.
Section 743B.005 - Definitions.
Section 743B.011 - Group health benefit plans subject to provisions of specified laws; exemptions.
Section 743B.013 - Requirements for small employer health benefit plans.
Section 743B.020 - Eligible employees and small employers; rules.
Section 743B.100 - Department’s authority to regulate market.
Section 743B.103 - Use of health-related information.
Section 743B.105 - Requirements for group health benefit plans other than small employer plans.
Section 743B.109 - Short term health insurance policies; rules.
Section 743B.128 - Exceptions to requirement to actively market all plans.
Section 743B.129 - Shortening period of exclusion following discontinued offering; rules.
Section 743B.130 - Requirement to offer bronze and silver plans; rules.
Section 743B.200 - Requirements for insurers offering managed health insurance; quality assessment.
Section 743B.225 - Continuity of care.
Section 743B.227 - Referrals to specialists.
Section 743B.252 - External review; rules.
Section 743B.254 - Required statements regarding external reviews.
Section 743B.256 - Duties of independent review organizations; expedited reviews.
Section 743B.258 - Private right of action.
Section 743B.280 - Definitions for ORS 743B.280 to 743B.285.
Section 743B.281 - Estimate of costs for in-network procedure or service.
Section 743B.282 - Estimate of costs for out-of-network procedure or service.
Section 743B.283 - Submission of methodology used to determine insurer’s allowable charges.
Section 743B.284 - Alternative mechanism for disclosure of costs and charges.
Section 743B.287 - Balance billing prohibited for health care facility services.
Section 743B.290 - Hospital payment of copayment or deductible for insured patient.
Section 743B.310 - Rescinding coverage; permissible bases; notice; rules.
Section 743B.324 - Rules for certain notice requirements.
Section 743B.344 - Procedure for obtaining continuation of coverage under ORS 743B.343.
Section 743B.403 - Insurer prohibited practices; patient communication and referral.
Section 743B.406 - Vision care providers.
Section 743B.407 - Naturopathic physicians.
Section 743B.420 - Prior authorization requirements.
Section 743B.423 - Utilization review requirements for insurers offering health benefit plan.
Section 743B.424 - Applicability.
Section 743B.450 - Prompt payment of claims; limits on use of electronic payment methods; rules.
Section 743B.451 - Refund of paid claims.
Section 743B.452 - Interest on unpaid claims.
Section 743B.453 - Underpayment of claims.
Section 743B.454 - Claims submitted during credentialing period.
Section 743B.458 - Performance-based incentive payments for primary care.
Section 743B.460 - Conditions for restricting payments to only in-network providers.
Section 743B.462 - Direct payments to providers.
Section 743B.475 - Guidelines for coordination of benefits; rules.
Section 743B.500 - Selling and leasing of provider panels by contracting entity; definitions.
Section 743B.501 - Registration of contracting entity.
Section 743B.502 - Third party contracts for leasing of provider panels; requirements.
Section 743B.503 - Additional requirements for third party contracts.
Section 743B.505 - Provider networks; rules.
Section 743B.555 - Confidential communications.
Section 743B.601 - Synchronization of prescription drug refills.
Section 743B.602 - Step therapy.
Section 743B.800 - Risk adjustment procedures; rules.
Section 743B.810 - Enrollees covered by workers’ compensation.