(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 recommendations regarding the necessity or appropriateness of services or the site at which the services are provided and shall consult as appropriate with medical and mental health specialists in making such recommendations.
(3) Any patient or provider who has had a request for treatment or payment for services denied as not medically necessary or as experimental shall be provided an opportunity for a timely appeal before an appropriate medical consultant or peer review committee.
(4) Except as provided in subsection (5) of this section, a determination on a provider’s or an enrollee’s request for prior authorization of a nonemergency service must be issued within a reasonable period of time appropriate to the medical circumstances but no later than two business days after receipt of the request, and qualified health care personnel must be available for same-day telephone responses to inquiries concerning certification of continued length of stay.
(5) If additional information from an enrollee or a provider is necessary to make a determination on a request for prior authorization, no later than two business days after receipt of the request, the enrollee and the provider shall be notified in writing of the specific additional information needed to make the determination. The determination must be issued by the later of:
(a) Two business days after receipt of a response to the request for additional information; or
(b) Fifteen days after the date of the request for additional information unless otherwise provided by federal law. [Formerly 743.806; 2017 c.409 §38; 2019 c.284 §3; 2021 c.205 §12]
Note: See note under 743B.405.
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.