Current through Register Vol. 63, No. 9, September 1, 2024
(1) To comply with
the requirements in ORS
743B.250, on or before June 30
of each calendar year, an insurer must submit information pertaining to
grievances and prior authorizations in the previous calendar year ending
December 31. The data must be reported in the format prescribed by the director
of the Department of Consumer and Business Services as set forth on the website
of the Division of Financial Regulation of the Department of Consumer and
Business Services at dfr.oregon.gov. Filing and reporting requirements in this
rule apply to:
(a) A domestic insurer;
and
(b) A foreign insurer
transacting $2 million or more in health benefit plan premium in Oregon during
the calendar year immediately preceding the due date of a required
report.
(2) For purposes
of this rule, a grievance is "closed" if:
(a)
The grievance has been appealed through all available grievance appeal levels;
or
(b) The insurer determines that
the complainant is no longer pursuing the grievance.
(3) The grievance data to be included in the
annual summary required by section 1 of this rule are as follows:
(a) The total number of grievances closed in
the reporting year;
(b) The number
of grievances closed in each of the categories listed in section 4 of this
rule;
(c) The number and percentage
of grievances in each of the categories listed in section 4 of this rule in
which the insurer's initial decision is upheld and the number and percentage in
which the initial decision is reversed at closure of the grievance;
(d) The number and percentage of all
grievances that are closed at the conclusion of the first level of
appeal;
(e) The number and
percentage of all grievances that are closed at the conclusion of the second
level of appeal;
(f) The number and
percentage of all grievances that result in applications for external review;
and
(g) For each level of appeal
listed in subsections d and e of this section, the average length of time
between the date an enrollee files the appeal and the date an insurer sends
written notice of the insurer's determination for that appeal to the enrollee,
or person filing the appeal on behalf of the enrollee.
(4) An insurer must report each grievance
according to the nature of the grievance. The nature of the grievance shall be
determined according to the categories listed in this section. The insurer must
report each grievance in one category only and must have a system that allows
the insurer to report accurately in the specified categories. If a grievance
could fit in more than one category, an insurer shall report the grievance in
the category established in this section that the insurer determines to be most
appropriate for the grievance. The categories of grievances are as follows:
(a) Adverse benefit determinations based on
medical necessity under ORS
743.857;
(b) Adverse benefit determinations based on
an insurer's determination that a plan or course of treatment is experimental
or investigational under ORS
743.857;
(c) Continuity of care as defined in ORS
743.854;
(d) Access and referral problems including
timelines and availability of a provider and quality of clinical
care;
(e) Whether a course or plan
of treatment is delivered in an appropriate health care setting and with the
appropriate level of care;
(f)
Adverse benefit determinations of otherwise covered benefits due to imposition
of a source-of-injury exclusion, out-of-network or out-of-plan exclusion,
annual benefit limits or other limitations of otherwise covered benefits, or
imposition of a preexisting condition exclusion in a grandfathered health
plan;
(g) Adverse benefit
determinations based on general exclusions, not a covered benefit or other
coverage issues not listed in this section;
(h) Eligibility for, or termination of
enrollment, rescission or cancelation of a policy or certificate;
(i) Quality of plan services, not including
the quality of clinical care as provided in subsection d of this
section;
(j) Emergency services;
and
(k) Administrative issues and
issues other than those otherwise listed in this section.
(5) Nothing in this rule prohibits an insurer
from creating or using its own system to categorize the nature of grievances in
order to collect data if the system allows the insurer to report grievances
accurately according to the categories in section 4 of this rule and if the
system enables the director to track the grievances accurately.
(6) The prior authorization data to be
included in the annual summary required by section 1 of this rule are as
follows:
(a) The number of prior authorization
requests received;
(b) The number
of requests that were initially denied and the reasons for the denials,
including, but not limited to, lack of medical necessity or failure to provide
additional clinical information requested by the insurer;
(c) The number of requests that were
initially approved;
(d) The number
of denials that were reversed by internal appeals or external reviews;
and
(e) The number of requests for
which the entire requested item or service was not approved, but a specified
portion of the requested item or service or a specified alternative item or
service was approved.
Statutory/Other Authority: ORS
743B.250, ORS
743B.420, ORS
743B.422, ORS
743B.423, ORS
746.233 & Or Laws 2021, ch
154
Statutes/Other Implemented: ORS
743B.250, ORS
743B.420, ORS
743B.422, ORS
743B.423, ORS
746.233 & Or Laws 2021, ch
154
