Utilization review requirements for insurers offering health benefit plan
(1) All insurers offering a health benefit plan in this state that provide utilization review or have utilization review provided on their behalf shall file an annual summary with the Department of Consumer and Business Services that describes all utilization review policies, including delegated utilization review functions, and documents the insurer’s procedures for monitoring of utilization review activities.
(2) All utilization review activities conducted pursuant to subsection (1) of this section shall comply with the following:
(a) The criteria used in the utilization review process and the method of development of the criteria shall be made available for review to contracting providers upon request.
(b) 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.
(c) Any 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.
(d) 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 743.807; 2017 c.409 §39]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.