Utilization review requirements for medical services contracts to which insurer not party
- • right to appeal
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 (Qualifications of applicant for license) to 677.228 (Automatic lapse of license for failure to pay registration fee or report change of location) 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) A provider request for prior authorization of nonemergency service must be answered within two business days, and qualified health care personnel must be available for same-day telephone responses to inquiries concerning certification of continued length of stay. [Formerly 743.806; 2017 c.409 §38]
Note: See note under 743B.405 (Medical services contract provisions).
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