Direct payments to providers
(1) As used in this section:
(a) “Health benefit plan” has the meaning given that term in ORS 743B.005 (Definitions).
(b) “Provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services, including substance use disorder services, in the ordinary course of business or practice of a profession.
(2) Except as provided in ORS 743.543 (Payment of benefits under blanket health insurance policies) and 743.550 (Student health insurance), a provider that bills an insurer for covered services provided to an individual who is insured under a health benefit plan or a Medicare supplement insurance policy issued by the insurer shall be reimbursed by the insurer by a direct payment issued to the provider. [2015 c.588 §2]
Note: 743B.462 (Direct payments to providers) 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.
Note: Sections 1, 2 and 4, chapter 694, Oregon Laws 2017, provide:
Sec. 1. (1) As used in this section:
(a) “Behavioral mental health provider” includes:
(B) A clinical social worker licensed under ORS 675.530 (License); and
(C) A professional counselor or marriage and family therapist licensed under ORS 675.715 (Application).
(b) “Carrier” has the meaning given that term in ORS 743B.005 (Definitions).
(c) “Medical provider” means a physician licensed under ORS chapter 677.
(d) “Mental health provider with prescribing privileges” includes:
(A) A psychiatrist; and
(B) A certified nurse practitioner with a specialty in psychiatric mental health.
(2) The Department of Consumer and Business Services shall examine all of the following:
(a) The historical trends of each carrier’s maximum allowable reimbursement rates for time-based outpatient office visit procedural codes and whether each carrier’s in-network behavioral mental health providers have been paid reimbursement that is equivalent to the reimbursement for the carrier’s in-network medical providers and mental health providers with prescribing privileges.
(b) Whether each carrier imposes utilization management procedures for behavioral mental health providers that are more restrictive than the utilization management procedures for medical providers as indicated by the time-based outpatient office visit procedural codes applied to providers in each category, including a review of whether a carrier restricts the use of longer office visits for behavioral mental health providers more than for medical providers.
(c) Whether each carrier pays equivalent reimbursement for time-based procedural codes for both in-network behavioral mental health providers and in-network medical providers, including the reimbursement of incremental increases in the length of an office visit.
(d) Whether the methodologies used by each carrier to determine the carrier’s reimbursement rate schedule are equivalent for in-network behavioral health providers and in-network medical providers.
(3) The department shall adopt rules or take other actions based on the results of the department’s examination under subsection (2) of this section that ensure that carriers meet the requirements of ORS 743A.168 (Treatment of chemical dependency, including alcoholism, and mental or nervous conditions) and 743B.505 (Provider networks) in policies, certificates or contracts for health insurance that the carriers offer to residents of this state. [2017 c.694 §1]
Sec. 2. The Department of Consumer and Business Services shall report to the interim committees of the Legislative Assembly related to health, no later than September 1, 2019, the status of the department’s examination in accordance with section 1 of this 2017 Act and rules adopted or other actions taken by the department in response to the examination. [2017 c.694 §2]
Sec. 4. Section 1 of this 2017 Act is repealed on January 2, 2021. [2017 c.694 §4]
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.