Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-1330 - Criteria and Considerations for External Review Determinations
Universal Citation: OR Admin Rules 836-053-1330
Current through Register Vol. 63, No. 9, September 1, 2024
(1) The following criteria and considerations apply to decisions by an independent review organization:
(a) An independent review
organization must use fair procedures in making a decision, and the decision
must be consistent with the standards in ORS
743B.253 and
743B.256 and OAR
836-053-1300 to
836-053-1365.
(b) An independent review organization may
override the standards of a health benefit plan governing the coverage issues
that are subject to independent review pursuant to ORS
743B.252(1)
only if the standards are determined upon review to be unreasonable or
inconsistent with sound, evidence-based medical practice.
(2) A decision by an independent review organization of a dispute relating to an adverse decision by an insurer is subject to enforcement under ORS 743B.252 to 743B.258 if:
(a) The dispute relates to an adverse
decision on one or more of the following:
(A)
Whether a course or plan of treatment is medically necessary;
(B) Whether a course or plan of treatment is
experimental or investigational; or
(C) Whether a course or plan of treatment
that an enrollee is undergoing is an active course of treatment for purposes of
continuity of care under ORS
743B.225;
and
(b) The decision by
the independent review organization is made in accordance with the coverage
described in the health benefit plan, including limitations and exclusions
expressed in the plan, except that the independent review organization may
override the insurer's standards for medically necessary or experimental or
investigational treatment, if the independent review organization determines
that:
(A) The standards of the insurer are
unreasonable or are inconsistent with sound medical practice; or
(B) For cases in which the insurer's decision
addressed whether a course or plan of treatment was medically necessary:
(i) The insurer's decision did not conform to
the insurer's definition of medically necessary in the relevant health
insurance policy, or
(ii) The
insurer's decision did not conform to the requirement that the definition of
medical necessity be uniformly applied; or
(C) For cases in which the insurer's decision
addressed whether a course or plan of treatment was experimental or
investigational:
(i) The insurer's decision
did not conform to the insurer's definition of experimental or investigational
in the relevant health insurance policy, or
(ii) The insurer's decision did not conform
to the requirement that the definition of experimental or investigational be
uniformly applied.
(3) No provision of OAR 836-053-1300 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action.
Statutory/Other Authority: ORS 731.244 & ORS 743B.253
Statutes/Other Implemented: ORS 743B.253, ORS 743B.225, ORS 743B.252, ORS 743B.256 & ORS 743B.258
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