Or. Admin. Code § 836-053-1130 - Annual Summary, Utilization Review

(1) To comply with the requirements of ORS 743.807, an insurer must electronically submit on or before June 30 of each calendar year, an annual utilization review program summary for the preceding calendar year to the Division of Financial Regulation in the format required 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 calendar year 2014 and each subsequent calendar year the annual summary required by section (1) of this rule must:

(a) Describe the insurer's utilization review policies ;

(b) Provide a summary of established processes and monitoring activities for each of the following program areas:

(A) Program oversight;

(B) Utilization review criteria development, implementation and revision;

(C) List of clinical information, research publications and other information used in the development of pre-service authorization requirements, concurrent review and other utilization review activities;

(D) Provider program participation procedures;

(E) Minimum qualifications of utilization review decision makers;

(F) Time frames for utilization review decisions;

(G) Enrollee and provider communication processes; and

(H) Program monitoring, review, evaluation and update; and

(c) Document:

(A) Delegated utilization review activities, including monitoring and oversight activities of those to whom the activities are delegated; and

(B) Policies for review and audit of delegates and delegated activities.

(3) To minimize duplicative reporting requirements, an insurer may meet the reporting requirements of this rule by submitting to the department either of the following:

(a) A copy of a report prepared for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required.

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(4) An insurer may not submit addenda described in subsection (3)(b) of this rule in two consecutive years.

(5) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

Notes

Or. Admin. Code § 836-053-1130

ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 20-2023, minor correction filed 06/27/2023, effective 6/27/2023

Statutory/Other Authority: ORS 731.244 & 743.819

Statutes/Other Implemented: ORS 743.801, 743.804 & 743.807