2011 ORS § 743.801¹

As used in this section and ORS 743.803 (Medical services contract provisions), 743.804 (Required notices to applicants and enrollees), 743.806 (Utilization review requirements for medical services contracts to which insurer not party), 743.807 (Utilization review requirements for insurers offering health benefit plan), 743.808 (Requirements for insurers that require designation of participating primary care physician), 743.811 (Applicability), 743.814 (Requirements for insurers offering managed health insurance), 743.817 (Requirements for insurers offering managed health or preferred provider organization insurance), 743.819 (Reporting requirements), 743.821 (Required managed health insurance contract provision), 743.823 (Enforcement of Newborns and Mothers Health Protection Act of 1996), 743.827 (Health Care Consumer Protection Advisory Committee), 743.829 (Decisions regarding health care facility length of stay, level of care and follow-up care), 743.831 (Consortium established), 743.834 (Insurer prohibited practices), 743.837 (Prior authorization requirements), 743.839 (Disclosure of information), 743.854 (Continuity of care), 743.856 (Referrals to specialists), 743.857 (External review), 743.858 (Director to contract with independent review organizations to provide external review), 743.859 (Notice to enrollee of right to sue if insurer does not follow decision of independent review organization), 743.861 (Enrollee application for external review), 743.862 (Duties of independent review organizations), 743.863 (Civil penalty for failure to comply by insurer that agreed to be bound by decision), 743.864 (Private right of action), 743.894 (Rescinding coverage), 743.911 (Payment or denial of health benefit plan claims), 743.912 (Refund of paid claims), 743.913 (Interest on unpaid claims), 743.917 (Underpayment of claims) and 743.918 (Claims submitted during credentialing period):

(1) Adverse benefit determination means an insurers denial, reduction or termination of a health care item or service, or an insurers failure or refusal to provide or to make a payment in whole or in part for a health care item or service, that is based on the insurers:

(a) Denial of eligibility for or termination of enrollment in a health benefit plan;

(b) Rescission or cancellation of a policy or certificate;

(c) Imposition of a preexisting condition exclusion as defined in ORS 743.730 (Definitions for ORS 743.730 to 743.773), source-of-injury exclusion, network exclusion, annual benefit limit or other limitation on otherwise covered items or services;

(d) Determination that a health care item or service is experimental, investigational or not medically necessary, effective or appropriate; or

(e) Determination that a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743.854 (Continuity of care).

(2) Authorized representative means an individual who by law or by the consent of a person may act on behalf of the person.

(3) Enrollee has the meaning given that term in ORS 743.730 (Definitions for ORS 743.730 to 743.773).

(4) Grievance means:

(a) A request submitted by an enrollee or an authorized representative of an enrollee:

(A) In writing, for an internal appeal or an external review; or

(B) In writing or orally, for an expedited response described in ORS 743.804 (Required notices to applicants and enrollees) (2)(d) or an expedited external review; or

(b) A written complaint submitted by an enrollee or an authorized representative of an enrollee regarding the:

(A) Availability, delivery or quality of a health care service;

(B) Claims payment, handling or reimbursement for health care services and, unless the enrollee has not submitted a request for an internal appeal, the complaint is not disputing an adverse benefit determination; or

(C) Matters pertaining to the contractual relationship between an enrollee and an insurer.

(5) Health benefit plan has the meaning given that term in ORS 743.730 (Definitions for ORS 743.730 to 743.773).

(6) Independent practice association means a corporation wholly owned by providers, or whose membership consists entirely of providers, formed for the sole purpose of contracting with insurers for the provision of health care services to enrollees, or with employers for the provision of health care services to employees, or with a group, as described in ORS 743.522 (Group health insurance described), to provide health care services to group members.

(7) Insurer includes a health care service contractor as defined in ORS 750.005 (Definitions).

(8) Internal appeal means a review by an insurer of an adverse benefit determination made by the insurer.

(9) Managed health insurance means any health benefit plan that:

(a) Requires an enrollee to use a specified network or networks of providers managed, owned, under contract with or employed by the insurer in order to receive benefits under the plan, except for emergency or other specified limited service; or

(b) In addition to the requirements of paragraph (a) of this subsection, offers a point-of-service provision that allows an enrollee to use providers outside of the specified network or networks at the option of the enrollee and receive a reduced level of benefits.

(10) Medical services contract means a contract between an insurer and an independent practice association, between an insurer and a provider, between an independent practice association and a provider or organization of providers, between medical or mental health clinics, and between a medical or mental health clinic and a provider to provide medical or mental health services. Medical services contract does not include a contract of employment or a contract creating legal entities and ownership thereof that are authorized under ORS chapter 58, 60 or 70, or other similar professional organizations permitted by statute.

(11)(a) Preferred provider organization insurance means any health benefit plan that:

(A) Specifies a preferred network of providers managed, owned or under contract with or employed by an insurer;

(B) Does not require an enrollee to use the preferred network of providers in order to receive benefits under the plan; and

(C) Creates financial incentives for an enrollee to use the preferred network of providers by providing an increased level of benefits.

(b) Preferred provider organization insurance does not mean a health benefit plan that has as its sole financial incentive a hold harmless provision under which providers in the preferred network agree to accept as payment in full the maximum allowable amounts that are specified in the medical services contracts.

(12) Prior authorization means a determination by an insurer prior to provision of services that the insurer will provide reimbursement for the services. Prior authorization does not include referral approval for evaluation and management services between providers.

(13) Provider means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services in the ordinary course of business or practice of a profession.

(14) Utilization review means a set of formal techniques used by an insurer or delegated by the insurer designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy or efficiency of health care services, procedures or settings. [1995 c.672 §1; 1997 c.343 §18; 2001 c.266 §1; 2001 c.747 §5; 2003 c.87 §21; 2003 c.137 §§3,4; 2005 c.418 §2; 2009 c.806 §3; 2009 c.807 §4; 2011 c.500 §26]