Or. Admin. Code § 436-015-0040 - Reporting Requirements for an MCO
(1) In order to
ensure the MCO complies with the requirements of these rules, each MCO must
provide the director with a copy of the entire text of any MCO-insurer
contract, signed by the insurer and the MCO, within 30 days of execution of
such contracts. The MCO must submit any amendments, addenda, or cancellations
to the director within 30 days of execution.
(2) When an MCO-insurer contract contains a
specific expiration or termination date, the MCO must provide the director with
a copy of a contract extension, signed by the insurer and MCO, no later than
the contract's date of expiration or termination. If the MCO does not provide
the director with a copy of the signed contract extension, workers will no
longer be subject to the contract after it expires or terminates.
(3) The MCO must submit any amendments to the
certified plan to the director for approval. The MCO must not take any action
based on a proposed amendment until the director approves the
amendment.
(4) Within 45 days of
the end of each calendar quarter, each MCO must provide the following
information to the director, current on the last day of the quarter, as
described in Bulletin 247:
(a) The quarter
being reported;
(b) MCO
certification number; and
(c)
Membership listings by category of medical service provider (in coded form),
including:
(A) Provider names;
(B) Specialty (in coded form);
(C) Tax ID number;
(D) National Provider Identifier (NPI)
number; and
(E) Business address
and phone number. When a medical service provider has multiple offices, only
one office location in each geographic service area needs to be
reported.
(5)
By April 30 of each year, each MCO must provide the director with the following
information for the previous calendar year:
(a) A summary of any sanctions or punitive
actions taken by the MCO against its members; and
(b) A summary of actions taken by the MCO's
peer review committee.
(6) By April 30 of each year, each MCO must
report to the director denials and terminations of the authorization of
come-along providers. The MCO's report must include the following:
(a) Provider type (primary care physician,
chiropractic physician, physician associate or authorized nurse practitioner)
reported by geographic service area (GSA).
(b) The number of workers affected, reported
by provider type.
(c) Date of
denial or termination.
(d) One or
more of the following reasons for each denial or termination:
(A) Provider failed to meet the MCO's
credentialing standards within the last two years;
(B) Provider has been previously terminated
from serving as an attending physician within the last two years;
(C) Treatment is not according to the MCO's
service utilization process;
(D)
Provider failed to comply with the MCO's terms and conditions after being
granted come-along privileges; or
(E) Other reasons authorized by statute or
rule.
(7) An
MCO must report any new board members or shareholders to the director within 14
days of such changes. These parties must submit affidavits certifying they have
no interest in an insurer or other non-qualifying employer as described under
OAR 436-015-0009.
(8) Nothing in this rule limits the
director's ability to require information from the MCO as necessary to monitor
the MCO's compliance with the requirements of these rules.
Notes
Statutory/Other Authority: ORS 656.726(4) & ORS 656.260
Statutes/Other Implemented: ORS 656.260
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.