2017 ORS 743B.454¹
Claims submitted during credentialing period

This section is amended
Effective April 3, 2018
Relating to residential care facilities; creating new provisions; amending ORS 401.651, 431A.850, 433.045, 441.057, 441.406, 676.108, 676.150, 676.350, 676.400, 676.565, 676.595, 676.850, 676.992, 678.710, 678.720, 678.740, 678.770, 678.800, 678.810, 678.820 and 743B.454; and declaring an emergency.

(1) As used in this section:

(a) “Complete application” means a provider’s application to a health insurer to become a credentialed provider that includes:

(A) Information required by the health insurer;

(B) Proof that the provider is licensed by a health professional regulatory board as defined in ORS 676.160 (Definitions for ORS 676.165 to 676.180), the Nursing Home Administrators Board, the Board of Licensed Dietitians or the Behavior Analysis Regulatory Board;

(C) Proof of current registration with the Drug Enforcement Administration of the United States Department of Justice, if applicable to the provider’s practice; and

(D) Proof that the provider is covered by a professional liability insurance policy or certification meeting the health insurer’s requirements.

(b) “Credentialing period” means the period beginning on the date a health insurer receives a complete application and ending on the date the health insurer approves or rejects the complete application or 90 days after the health insurer receives the complete application, whichever is earlier.

(c) “Health insurer” means an insurer that offers managed health insurance or preferred provider organization insurance, other than a health maintenance organization as defined in ORS 750.005 (Definitions).

(2) A health insurer shall approve or reject a complete application within 90 days of receiving the application.

(3)(a) A health insurer shall pay all claims for medical services covered by the health insurer that are provided by a provider during the credentialing period.

(b) A provider may submit claims for medical services provided during the credentialing period during or after the credentialing period.

(c) A health insurer may pay claims for medical services provided during the credentialing period:

(A) During or after the credentialing period.

(B) At the rate paid to nonparticipating providers.

(d) If a provider submits a claim for medical services provided during the credentialing period within six months after the end of the credentialing period, the health insurer may not deny payment of the claim on the basis of the health insurer’s rules relating to timely claims submission.

(4) Subsection (3) of this section does not require a health insurer to pay claims for medical services provided during the credentialing period if:

(a) The provider was previously rejected or terminated as a participating provider in any health benefit plan underwritten or administered by the health insurer;

(b) The rejection or termination was due to the objectively verifiable failure of the provider to provide medical services within the recognized standards of the provider’s profession; and

(c) The provider was given the opportunity to contest the rejection or termination before a panel of peers in a proceeding conducted in conformity with the Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq. [Formerly 743.918; 2017 c.101 §23]

Note: 743B.454 (Claims submitted during credentialing period) was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.

1 Legislative Counsel Committee, CHAPTER 743B—Health Benefit Plans: Individual and Group, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors743B.­html (2017) (last ac­cessed Mar. 30, 2018).
2 OregonLaws.org contains the con­tents of Volume 21 of the ORS, inserted along­side the per­tin­ent statutes. See the preface to the ORS An­no­ta­tions for more information.
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.