ORS 743B.001
Definitions


As used in this section and ORS 743.008 (Reporting requirements), 743.029 (Uniform standards for health care financial and administrative transactions), 743.035 (Uniform prior authorization form for prescription drug benefits), 743A.190 (Children with pervasive developmental disorder), 743B.195 (Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996), 743B.197 (Health Care Consumer Protection Advisory Committee), 743B.200 (Requirements for insurers offering managed health insurance), 743B.202 (Requirements for insurers offering managed health or preferred provider organization insurance), 743B.204 (Required managed health insurance contract provision), 743B.220 (Requirements for insurers that require designation of participating primary care physician), 743B.225 (Continuity of care), 743B.227 (Referrals to specialists), 743B.250 (Required notices to applicants and enrollees), 743B.252 (External review), 743B.253 (Director to contract with independent review organizations to provide external review), 743B.254 (Required statements regarding external reviews), 743B.255 (Enrollee application for external review), 743B.256 (Duties of independent review organizations), 743B.257 (Civil penalty for failure to comply by insurer that agreed to be bound by decision), 743B.258 (Private right of action), 743B.310 (Rescinding coverage), 743B.400 (Decisions regarding health care facility length of stay, level of care and follow-up care), 743B.403 (Insurer prohibited practices), 743B.405 (Medical services contract provisions), 743B.420 (Prior authorization requirements), 743B.422 (Utilization review requirements for medical services contracts to which insurer not party), 743B.423 (Utilization review requirements for insurers offering health benefit plan), 743B.424 (Applicability), 743B.450 (Prompt payment of claims), 743B.451 (Refund of paid claims), 743B.452 (Interest on unpaid claims), 743B.453 (Underpayment of claims), 743B.454 (Claims submitted during credentialing period), 743B.505 (Provider networks), 743B.550 (Disclosure of information), 743B.555 (Confidential communications) and 743B.602 (Step therapy):

(1)

“Adverse benefit determination” means an insurer’s denial, reduction or termination of a health care item or service, or an insurer’s 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 insurer’s:

(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 743B.005 (Definitions), 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;

(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 743B.225 (Continuity of care); or

(f)

Denial, in whole or in part, of a request for prior authorization, a request for an exception to step therapy or a request for coverage of a treatment, drug, device or diagnostic or laboratory test that is subject to other utilization review requirements.

(2)

“Authorized representative” means an individual who by law or by the consent of a person may act on behalf of the person.

(3)

“Clinical review criteria” means screening procedures, decision rules, medical protocols and clinical guidance used by an insurer or other entity in conducting utilization review and evaluating:

(a)

Medical necessity;

(b)

Appropriateness of an item or health service for which prior authorization is requested or for which an exception to step therapy has been requested as described in ORS 743B.602 (Step therapy); or

(c)

Any other coverage that is subject to utilization review.

(4)

“Credit card” has the meaning given that term in 15 U.S.C. 1602.

(5)

“Electronic funds transfer” has the meaning given that term in ORS 293.525 (Payments to and by state agencies by electronic funds transfers).

(6)

“Enrollee” has the meaning given that term in ORS 743B.005 (Definitions).

(7)

“Essential community provider” has the meaning given that term in rules adopted by the Department of Consumer and Business Services consistent with the description of the term in 42 U.S.C. 18031 and the rules adopted by the United States Department of Health and Human Services, the United States Department of the Treasury or the United States Department of Labor to carry out 42 U.S.C. 18031.

(8)

“Grievance” means:

(a)

A communication from an enrollee or an authorized representative of an enrollee expressing dissatisfaction with an adverse benefit determination, without specifically declining any right to appeal or review, that is:

(A)

In writing, for an internal appeal or an external review; or

(B)

In writing or orally, for an expedited response described in ORS 743B.250 (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.

(9)

“Health benefit plan” has the meaning given that term in ORS 743B.005 (Definitions).

(10)

“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 731.098 (“Group health insurance.”), to provide health care services to group members.

(11)

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

(12)

“Internal appeal” means a review by an insurer of an adverse benefit determination made by the insurer.

(13)

“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.

(14)

“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.

(15)

Intentionally left blank —Ed.

(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.

(16)

“Prior authorization” means a form of utilization review that requires a provider or an enrollee to request a determination by an insurer, prior to the provision of health care that is subject to utilization review, that the insurer will provide reimbursement for the health care requested. “Prior authorization” does not include referral approval for evaluation and management services between providers.

(17)

Intentionally left blank —Ed.

(a)

“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.

(b)

With respect to the statutes governing the billing for or payment of claims, “provider” also includes an employee or other designee of the provider who has the responsibility for billing claims for reimbursement or receiving payments on claims.

(18)

“Step therapy” means a utilization review protocol, policy or program in which an insurer requires certain preferred drugs for treatment of a specific medical condition be proven ineffective or contraindicated before a prescribed drug may be reimbursed.

(19)

“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 items, services, procedures or settings. [Formerly 743.801; 2017 c.101 §54; 2017 c.384 §10; 2019 c.284 §§8,12; 2021 c.154 §§7,8]

Source: Section 743B.001 — Definitions, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743B.­html.

743B.001
Definitions
743B.003
Purposes
743B.005
Definitions
743B.010
Issuance of group health benefit plan to affiliated group of employers
743B.011
Group health benefit plans subject to provisions of specified laws
743B.012
Requirement to offer all health benefit plans to small employers
743B.013
Requirements for small employer health benefit plans
743B.020
Eligible employees and small employers
743B.100
Department’s authority to regulate market
743B.102
Certifications and disclosure of coverage
743B.103
Use of health-related information
743B.104
Coverage in group health benefit plans
743B.105
Requirements for group health benefit plans other than small employer plans
743B.109
Short term health insurance policies
743B.110
Implementation of federal laws
743B.125
Individual health benefit plans
743B.126
Carrier marketing of individual health benefit plans
743B.127
Rules for ORS 743.022, 743B.125 and 743B.126
743B.128
Exceptions to requirement to actively market all plans
743B.129
Shortening period of exclusion following discontinued offering
743B.130
Requirement to offer bronze and silver plans
743B.195
Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996
743B.197
Health Care Consumer Protection Advisory Committee
743B.200
Requirements for insurers offering managed health insurance
743B.202
Requirements for insurers offering managed health or preferred provider organization insurance
743B.204
Required managed health insurance contract provision
743B.220
Requirements for insurers that require designation of participating primary care physician
743B.222
Designation of women’s health care provider as primary care provider
743B.225
Continuity of care
743B.227
Referrals to specialists
743B.250
Required notices to applicants and enrollees
743B.252
External review
743B.253
Director to contract with independent review organizations to provide external review
743B.254
Required statements regarding external reviews
743B.255
Enrollee application for external review
743B.256
Duties of independent review organizations
743B.257
Civil penalty for failure to comply by insurer that agreed to be bound by decision
743B.258
Private right of action
743B.260
Claims and appeals of adverse benefit determinations under disability income insurance policies
743B.280
Definitions for ORS 743B.280 to 743B.285
743B.281
Estimate of costs for in-network procedure or service
743B.282
Estimate of costs for out-of-network procedure or service
743B.283
Submission of methodology used to determine insurer’s allowable charges
743B.284
Alternative mechanism for disclosure of costs and charges
743B.285
Rules
743B.287
Balance billing prohibited for health care facility services
743B.290
Hospital payment of copayment or deductible for insured patient
743B.300
Disclosure of differences in replacement health insurance policies
743B.310
Rescinding coverage
743B.320
Minimum grace period
743B.321
Applicability of ORS 743B.320
743B.323
Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium
743B.324
Rules for certain notice requirements
743B.330
Notice to policyholder required for cancellation or nonrenewal of health benefit plan
743B.340
When group health insurance policies to continue in effect upon payment of premium by insured individual
743B.341
Continuation of benefits after termination of group health insurance policy
743B.342
Continuation of benefits after injury or illness covered by workers’ compensation
743B.343
Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older
743B.344
Procedure for obtaining continuation of coverage under ORS 743B.343
743B.345
Premium for continuation of coverage under ORS 743B.344
743B.347
Continuation of coverage under group policy upon termination of membership in group health insurance policy
743B.400
Decisions regarding health care facility length of stay, level of care and follow-up care
743B.403
Insurer prohibited practices
743B.405
Medical services contract provisions
743B.406
Vision care providers
743B.407
Naturopathic physicians
743B.420
Prior authorization requirements
743B.422
Utilization review requirements for medical services contracts to which insurer not party
743B.423
Utilization review requirements for insurers offering health benefit plan
743B.424
Applicability
743B.425
Prior authorization prohibited for first 60 days of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs
743B.427
Nonquantitative treatment limitations on coverage of behavioral health conditions
743B.450
Prompt payment of claims
743B.451
Refund of paid claims
743B.452
Interest on unpaid claims
743B.453
Underpayment of claims
743B.454
Claims submitted during credentialing period
743B.458
Performance-based incentive payments for primary care
743B.460
Conditions for restricting payments to only in-network providers
743B.462
Direct payments to providers
743B.470
Medicaid not considered in coverage eligibility determination
743B.475
Guidelines for coordination of benefits
743B.500
Selling and leasing of provider panels by contracting entity
743B.501
Registration of contracting entity
743B.502
Third party contracts for leasing of provider panels
743B.503
Additional requirements for third party contracts
743B.505
Provider networks
743B.550
Disclosure of information
743B.555
Confidential communications
743B.601
Synchronization of prescription drug refills
743B.602
Step therapy
743B.800
Risk adjustment procedures
743B.810
Enrollees covered by workers’ compensation
Green check means up to date. Up to date