Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-1404 - Definitions; Noncontracting Providers; Co-Morbidity Disorders
Universal Citation: OR Admin Rules 836-053-1404
Current through Register Vol. 63, No. 9, September 1, 2024
(1) As used in ORS 743A.168 and OAR Chapter 836:
(a) "Behavioral health condition" means any
mental or substance use disorder covered by diagnostic categories listed in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text
Revision (DSM-5-TR), the International Classification of Diseases, 10th
Revision (ICD-10), or the International Classification of Diseases, 11th
Revision (ICD-11).
(b) "Generally
accepted standards of care" means;
(A)
Standards of care and clinical practice guidelines that:
(i) Are generally recognized by health care
providers practicing in relevant clinical specialties; and
(ii) Are based on valid, evidence-based
sources; and
(B)
Products and services that:
(i) Address the
specific needs of a patient for the purpose of screening for, preventing,
diagnosing, managing or treating an illness, injury or condition or symptoms of
an illness, injury or condition;
(ii) Are clinically appropriate in terms of
type, frequency, extent, site and duration; and
(iii) Are not primarily for the economic
benefit of an insurer or payer or for the convenience of a patient, treating
physician or other health care provider.
(c) "Valid, evidence-based sources" includes
but is not limited to:
(A) Peer-reviewed
scientific studies and medical literature;
(B) Recommendations of nonprofit health care
provider professional associations, and;
(C) Specialty societies.
(2) A non-contracting provider must cooperate with a health insurer's requirements for review of treatment in ORS 743A.168(2) and (3) to the same extent as a contracting provider in order to be eligible for reimbursement.
(3) The exception of a disorder in the definition of "behavioral health condition" in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder.
Statutory/Other Authority: ORS 731.244 & ORS 743A.168
Statutes/Other Implemented: ORS 743A.168
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