Current through Register Vol. 63, No. 9, September 1, 2024
(1) This rule is
adopted under the authority of ORS
731.244 and
744.704 for the purpose of
establishing exemptions under and implementing ORS
744.704(1)(p).
The persons described in this rule are exempt from the licensing requirement
for third party administrators in ORS
744.702 and from all other
provisions of ORS 744.700 to
744.740.
(2) The Department of Human Resources and any
organization contracting with the Department of Human Resources for that
portion of its business covered under a contract with the Department are
exempt.
(3) A health care provider
that contracts with an insurer to provide health care services to insurance
plan enrollees and is compensated for such services on a prepaid, capitated or
similar basis is exempt when the insurer and the provider operate under a
written agreement that includes all of the conditions specified in this
section. For the purpose of this section, a "health care provider" or
"provider" means a licensed health care practitioner or a group of such
practitioners, a licensed health care facility or group of such facilities and
any similar health care organization. The conditions required to be included in
the agreement are as follows:
(a) The primary
contractual responsibility of the provider is the delivery of health care
services to insurance plan enrollees and the administrative duties performed by
the provider for the insurer are in support of the delivery of health care
services;
(b) The administrative
duties performed by the provider for the insurer are limited to the adjusting
or settling of claims for insurance plan enrollees and the insurer retains
responsibility for providing competent administration of its
programs;
(c) The insurer performs
all functions that pertain to soliciting and effecting coverage, underwriting,
collecting premiums, determining plan benefits, determining premium rates and
securing any reinsurance for the insurer's obligations;
(d) The rules pertaining to the adjusting or
settling of claims are provided in writing by the insurer to the
provider;
(e) The insurer at least
annually conducts a review of the claims-related activities performed by the
provider for the insurer to ensure that those operations are in compliance with
subsection (b) of this section;
(f)
The provider allows the insurer access to the administrative books and records
of the provider that document the claims-related activities performed for the
insurer for the purpose of assuring the proper administration of claims, and
the insurer agrees to make those books and records available for examination by
the Director in accordance with ORS
731.300,
731.304 and
731.308;
(g) The provider allows the insurer access to
the relevant financial books and records of the provider that will enable the
insurer to determine the financial ability of the provider to fulfill its
responsibilities under the agreement, and both parties assure that
confidentiality of financial and patient records is maintained in accordance
with applicable federal and state requirements;
(h) The insurer makes certain that the
administrative books and records of the provider that document the
claims-related activities performed for the insurer are maintained by the
provider in accordance with prudent standards of insurance record-keeping and
that such books and records are maintained by the provider for a period of not
less than five years from the date of their creation; and
(i) The conditions applicable to the provider
in subsections (f) and (h) of this section must not be terminated upon a
termination of the agreement, whether by rescission or otherwise.
Stat. Auth.: ORS
731.244 & ORS 744.304
Stats. Implemented: ORS
744.704
