Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-0350 - Provider Directory Requirements for Network Adequacy
Universal Citation: OR Admin Rules 836-053-0350
Current through Register Vol. 63, No. 9, September 1, 2024
(1)
(a) An
insurer shall post electronically a current, accurate and complete provider
directory for each of its network plans with the information and search
functions, as described in section (2) of this rule.
(b) In making the directory available
electronically, the insurer shall ensure that the general public is able to
view all of the current providers for a plan through a clearly identifiable
link or tab and without creating or accessing an account or entering a policy
or contract number.
(c)
(A) An insurer shall update each network plan
provider directory at least monthly. The provider directory shall disclose the
frequency with which it is updated.
(B) The insurer shall include a disclosure in
the directory that the information included in the directory is accurate as of
the date posted to the web or printed and that enrollees or prospective
enrollees should consult the insurer to obtain current provider directory
information.
(d) An
insurer shall provide a print copy, or a print copy of the requested directory
information, of a current provider directory with the information described in
section (2) of this rule upon request of an enrollee or a prospective enrollee.
(e) For each network plan, an
insurer shall include in plain language in both the electronic and print
directory, the following general information:
(A) A description of the criteria the insurer
has used to build its provider network;
(B) If applicable, a description of the
criteria the insurer has used to tier providers;
(C) If applicable, information about how the
insurer designates the different provider tiers or levels in the network and
identifies for each specific provider, hospital, or other type of facility in
the network which tier each is placed, for example by name, symbols or
grouping, in order for an enrollee or a prospective enrollee to be able to
identify the provider tier; and
(D)
If applicable, note that authorization or referral may be required to access
some providers.
(f)
(A) An insurer shall make it clear in both
its electronic and print directories which provider directory applies to which
network plan, such as including the specific name of the network plan as
marketed and issued in this state.
(B) The insurer shall include in both its
electronic and print directories a customer service email address and telephone
number or electronic link that enrollees or the general public may use to
notify the insurer of inaccurate provider directory information.
(g) For the pieces of
information required under this section in a provider directory pertaining to a
health care professional, a hospital or a facility other than a hospital, the
insurer shall make available through the directory a general explanation of the
source of the information and any limitations, if applicable.
(h) A provider directory, whether in
electronic or print format, shall accommodate the communication needs of
individuals with disabilities, and include a link to or information regarding
available assistance for persons with limited English proficiency.
(2) The insurer shall make available through an electronic provider directory that includes search functions, for each network plan, all of the following information:
(a) For health care professionals:
(A) Name;
(B) Gender;
(C) Participating office locations;
(D) Specialty, if applicable;
(E) Participating facility
affiliations, if applicable;
(F)
Languages spoken by provider other than English, if applicable;
(G) Whether accepting new patients;
(H) Network affiliations;
(I) Tier level, if applicable;
(J) Contact information; and
(K) Board certifications.
(b) For hospitals:
(A) Hospital name;
(B) Participating hospital location;
(C) Hospital accreditation status;
(D) Network affiliations;
(E) Tier level, if applicable; and
(F) Telephone number.
(c) For facilities, other than
hospitals, by type:
(A) Facility name;
(B) Facility type;
(C) Participating facility locations;
(D) Network affiliations;
(E) Tier level, if applicable; and
(F) Telephone number.
Stat. Auth: ORS 731.244 and ORS 743B.505
Stats. Implemented: ORS 743B.505
Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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