Or. Admin. Code § 836-053-1200 - Prior Authorization Requirements for Health Benefit Plans
(1) The provisions
of this rule implement the requirements of ORS
743B.420, ORS
743B.422 and ORS
743B.423, as well amendments to
ORS 743B.420 and ORS
743B.423 by Oregon Laws 2021,
chapter 154 relating to prior authorization determinations. "Prior
authorization" means a form of utilization review that requires a provider or
an enrollee to request a determination by an insurer, prior to provision of
health care that is subject to utilization review, that the insurer will
provide reimbursement for the health care requested. "Prior authorization" does
not include referral approval for evaluation and management services between
providers. For the purposes of this rule, "health care" includes all items and
services covered by a health benefit plan, including but not limited to
medical, behavioral health, dental and vision care items and
services.
(2) This rule applies to
prior authorization determinations that:
(a)
Are issued orally or in writing by an insurer to a provider or enrollee
regarding the benefit coverage or medical necessity of a health care item or
service to be provided to an enrollee; and
(b) Are required under and obtained in
accordance with the terms of a health benefit plan.
(3) A prior authorization may be limited to
the services of a specific provider or to services of a designated group of
providers who contract with or are employed by the insurer.
(4) Nothing in this rule shall require a
health benefit plan to contain a prior authorization requirement.
(5) Except in the case of misrepresentation
relevant to a request for prior authorization, a prior authorization
determination shall be binding on the insurer for the period of time specified
in section 6 of this rule.
(6) A
prior authorization determination shall be binding on the insurer for:
(a) The lesser of the following periods:
(A) Five business days following the date of
issuance of the authorization; or
(B) The period during which the enrollee's
coverage remains in effect, provided that when the insurer issues the prior
authorization, the insurer has specific knowledge that the enrollee's coverage
will terminate sooner than five business days following the day the
authorization is issued and the insurer specifies the termination date in the
authorization; and
(b)
For an item or service other than a prescription drug, the period during which
the enrollee's coverage remains in effect beyond the time period established
pursuant to subsection a of this section, up to a maximum of 60 calendar days
or the reasonable duration of the treatment based on clinical standards,
whichever is longer.
(c) For a
prescription drug, the period during which the enrollee's coverage remains in
effect beyond the time period established pursuant to subsection a of this
section, up to a maximum of one calendar year from the date that the treatment
begins following approval of the request if the drug:
(A) Is prescribed as a maintenance therapy
that is expected to last at least 12 months based on medical or scientific
evidence;
(B) Continues to be
prescribed throughout the 12-month period; and
(C) Is prescribed for a condition that is
within the scope of use for the drug as approved by the United States Food and
Drug Administration; or has been proven to be a safe and effective form of
treatment for the enrollee's medical condition based on clinical practice
guidelines developed from peer-reviewed medical literature.
(d) Paragraph c of this subsection
does not apply if:
(A) A therapeutic
equivalent of the prescription drug or a generic alternative to the
prescription drug is or becomes available as a substitute for the drug for
which prior authorization is requested or was approved; or
(B) A biologic product is or becomes
available that is determined by the United States Food and Drug Administration
to be interchangeable with the drug for which prior authorization is requested
or approved.
(7) For purposes of counting days under
section 6 of this rule, day one is the first business or calendar day, as
applicable, following the day on which the insurer issues a prior authorization
determination.
(8) An insurer may
not impose a restriction or condition on its prior authorization determinations
that limits, restricts or effectively eliminates the binding force established
for such determinations in ORS
743B.420 and this
rule.
(9) A prior authorization
determination is issued when an insurer communicates orally, or in writing, a
notice that meets the requirements of section 11 of this rule to the provider
or enrollee who submitted the prior authorization request.
(10) Except as provided in section 13, a
determination by an insurer on a provider's or an enrollee's request for prior
authorization must be issued within a reasonable period of time appropriate to
the medical circumstances but no later than two business days after receipt of
the request. If the determination is issued orally, the insurer must mail, or
send electronically, a written notice of the determination to the provider or
enrollee who submitted the prior authorization request no later than two
business days after the determination is issued. For the purposes of counting
days under this subsection, day one is the first business day following the day
on which the insurer receives the request for prior authorization or issues the
determination, as applicable.
(11)
When an insurer issues a determination in response to a request from a provider
or an enrollee for prior authorization of nonemergency health care items or
services, the determination must be one of the following:
(a) The requested item or service is
authorized;
(b) The requested item
or service is not authorized; or
(c) The entire requested item or service is
not authorized, but a specified portion of the requested item or service or a
specified alternative item or service is authorized.
(12) If an insurer makes a determination
meeting the conditions specified in subsections b or c of section 11, the
notice of that determination must be mailed, or sent electronically, to the
enrollee who is the subject of the prior authorization request, regardless of
whether the enrollee submitted the prior authorization request to the insurer.
The notice must specify that the determination constitutes an adverse benefit
determination, and that the enrollee has the right to appeal the determination,
and to external review of the determination if applicable.
(13) If additional information from an
enrollee or a provider requesting prior authorization is necessary to make a
determination on a request for prior authorization, no later than two business
days after receipt of the request, the enrollee and the requesting provider, if
any, shall be notified in writing of the specific additional information needed
to make the determination. The required notice is provided when it is mailed,
or delivered electronically, by the insurer. For the purposes of counting days
under this subsection, day one is the first business day following the day on
which the insurer receives the request for prior authorization. Nothing in this
subsection shall be construed to prohibit an insurer from seeking additional
information related to a prior authorization request orally or by other means,
provided that a written notice is supplied in the event that a determination
cannot be made within two business days due to the need for additional
information.
(14) Following a
request for additional information submitted in compliance with section 13, the
insurer must issue a determination by the later of:
(a) Two business days after receipt of a
response to the request for additional information. For the purposes of
counting days under this subsection, day one is the first business day
following the day on which the insurer receives a response; or,
(b) Fifteen days after the date of the
request for additional information, unless otherwise provided in federal law.
For the purposes of counting days under this subsection, day one is the first
calendar day following the day on which the insurer mails, or sends
electronically, the request for additional information.
(15) When an insurer requests additional
information that is necessary to make a determination on a request for prior
authorization, the insurer must specify all of the information reasonably
necessary to make a determination. The insurer may not request information that
is substantially identical to information previously supplied by the enrollee
or provider.
(16) Compliance with
this rule by an insurer offering a health benefit plan will be sufficient to
demonstrate compliance with the requirement for insurers to act promptly in
making determinations in response to requests for prior authorization
established by ORS 746.233(2)(e).
Nothing in this rule shall be construed to limit the department's authority
under this section to require a health insurer to act equitably and in good
faith with respect to approving requests for prior authorization.
Notes
Statutory/Other Authority: ORS 743B.420, ORS 743B.422, ORS 743B.423, ORS 743B.250, ORS 746.233 & Or Laws 2021, ch 154
Statutes/Other Implemented: ORS 743B.420, ORS 743B.422, ORS 743B.423, ORS 743B.250, ORS 746.233 & Or Laws 2021, ch 154
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