§ 743B.500 — Selling and leasing of provider panels by contracting entity; definitions

Oregon § 743B.500

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

Text

As used in this section and ORS 743B.501 to 743B.503:
(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 or the services or rates of a provider panel under a provider network contract.
(b) “Contracting entity” includes a person under common ownership and control of a contracting entity.
(c) “Contracting entity” does not include:
(A) A managed care organization that is certified under ORS 656.260;
(B) A discount medical plan organization as defined in ORS 735.631;
(C) The state medical assistance program;
(D) An independent practice association; or
(E) A self-funded, employer-sponsored health insurance plan regulated under the Employee Retirement Income Security Act of 1974, as codified and amended at 29 U.S.C. 1001, et seq., or any person that provides only administrative services to the self-funded employer-sponsored health insurance plan.
(2) “Health care services” means the treatment of humans for bodily injury, disablement or death by accidental means or as a result of sickness or childbirth, or in prevention of sickness, but does not include treatment for bodily injury, disablement or occupational diseases incurred as a result of employment.
(3) “Independent practice association” has the meaning given that term in ORS 743B.001.
(4) “Person” has the meaning given that term in ORS 731.116.
(5)(a) “Provider” includes:
(A) A physician as defined in ORS 677.010.
(B) A physician group, independent practice association, physician-controlled organization, hospital organization or other provider organization that contracts with a provider for the purpose of facilitating the provider’s participation in a provider network contract.
(C) A person licensed, certified or otherwise authorized or permitted by the laws of this state to administer medical services or mental health services in the ordinary course of business or practice of a profession.
(b) “Provider” does not include a contracting entity.
(6) “Provider network contract” means a contract between a provider and a contracting entity for the provision of health care services to patients other than Medicare enrollees or medical assistance recipients.
(7)(a) “Third party” means a person that enters into a contract with a contracting entity or with another party, other than a provider, for the right to exercise the rights of the contracting entity under a provider network contract.
(b) “Third party” includes any of the following:
(A) A payer that directly reimburses the cost of the delivery of health care services;
(B) A third party administrator or other entity that administers or processes claims on behalf of a payer;
(C) A preferred provider organization or network;
(D) A physician-controlled organization or a hospital organization; or
(E) An entity that is engaged in the electronic transmission of claims between a contracting entity and a payer and does not provide to another party access to the health care services and discounted rates of a provider.
(c) “Third party” does not include:
(A) Entities offering health care services under the same brand pursuant to a brand licensing agreement with the same licenser; or
(B) A self-funded, employer-sponsored health insurance plan regulated under the Employee Retirement Income Security Act of 1974, as codified and amended at 29 U.S.C. 1001, et seq., or any person that provides only administrative services to the self-funded employer-sponsored health insurance plan.

Legislative History

Formerly 743.082