§ 743B.422 — Utilization review requirements for medical services contracts to which insurer not party; right to appeal

Oregon § 743B.422

• Jurisdiction: Oregon
• Vol.: 18
• Title 56: Insurance
• Ch. 743B: Health Benefit Plans: Individual and Group

Text

All utilization review performed pursuant to a medical services contract to which an insurer is not a party shall comply with the following:
(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.

Legislative History

Formerly 743.806; 2017 c.409 §38; 2019 c.284 §3; 2021 c.205 §12