This text of Oregon § 743B.454 (Claims submitted during credentialing period) is published on Counsel Stack Legal Research, covering Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(1)As used in this section:
(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 676.160, the Long Term Care Administrators Board, the Board of Licensed Dietitians or the Behavior Analysis Regulatory Board; (C)Proof of current registration with the Drug Enforcement Administration of the United States Department of Justice, if applicable to the provider’s practice; and
(D)Proof that the provider is covered by a professional liability insurance policy or certification meeting the health insurer’s requirements.
(b)“Credentialing period” means the period beginning on the
Free access — add to your briefcase to read the full text and ask questions with AI
(1) As used in this section:
(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 676.160, the Long Term Care Administrators Board, the Board of Licensed Dietitians or the Behavior Analysis Regulatory Board;
(C) Proof of current registration with the Drug Enforcement Administration of the United States Department of Justice, if applicable to the provider’s practice; and
(D) Proof that the provider is covered by a professional liability insurance policy or certification meeting the health insurer’s requirements.
(b) “Credentialing period” means the period beginning on the date a health insurer receives a complete application and ending on the date the health insurer approves or rejects the complete application or 90 days after the health insurer receives the complete application, whichever is earlier.
(c) “Health insurer” means an insurer that offers managed health insurance or preferred provider organization insurance, other than a health maintenance organization as defined in ORS 750.005.
(d) “In-network” has the meaning given that term in ORS 743B.275.
(e) “Out-of-network” has the meaning given that term in ORS 743B.275.
(2) A health insurer shall approve or reject a complete application within 90 days of receiving the application.
(3)(a) A health insurer shall pay all claims for medical services covered by the health insurer that are provided by a provider during the credentialing period.
(b) A provider may submit claims for medical services provided during the credentialing period during or after the credentialing period.
(c) A health insurer may pay claims for medical services provided during the credentialing period:
(A) During or after the credentialing period.
(B) At the rate paid to nonparticipating providers.
(d) Notwithstanding paragraph (c) of this subsection, if the application is for a health care provider joining a provider group that is in-network with the health insurer, the health insurer shall pay all claims for medical services covered by the health insurer that are provided by the provider during the credentialing period at the same rate and according to the same payment schedule as in-network providers. However, if the provider does not submit a complete application or does not meet credentialing requirements, the provider group shall reimburse the health insurer in an amount equal to the difference between in-network and out-of-network rates. Within 90 days from the date the health insurer receives the application, the health insurer, in complying with this paragraph, shall notify the provider that the application is not a complete application.
(e) If a provider submits a claim for medical services provided during the credentialing period within six months after the end of the credentialing period, the health insurer may not deny payment of the claim on the basis of the health insurer’s rules relating to timely claims submission.
(4) Subsection (3) of this section does not require a health insurer to pay claims for medical services provided during the credentialing period if:
(a) The provider was previously rejected or terminated as a participating provider in any health benefit plan underwritten or administered by the health insurer;
(b) The rejection or termination was due to the objectively verifiable failure of the provider to provide medical services within the recognized standards of the provider’s profession; and
(c) The provider was given the opportunity to contest the rejection or termination before a panel of peers in a proceeding conducted in conformity with the Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.