(1) An insurer offering health benefit plans in this state shall have an external review program that meets the requirements of this section and ORS 743.859 and 743.861. Each insurer shall provide the external review through an independent review organization that is under contract with the Director of the Department of Consumer and Business Services to provide external review. Each health benefit plan must allow an enrollee, by applying to the insurer, to obtain review by an independent review organization of a dispute relating to an adverse decision by the insurer on one or more of the following:
(a) Whether a course or plan of treatment is medically necessary.
(b) Whether a course or plan of treatment is experimental or investigational.
(c) Whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743.854.
(2) An insurer shall incur all costs of its external review program. The insurer may not establish or charge a fee payable by enrollees for conducting external review.
(3) When an enrollee applies for external review, the insurer shall request the director to appoint an independent review organization. When an independent review organization is appointed, the insurer shall forward all medical records and other relevant materials to the independent review organization and shall produce additional information as requested by the independent review organization to the extent that the information is reasonably available to the insurer. The insurer shall furnish all such records, materials and information in a timely manner in order to enable a timely decision by the independent review organization. The director may establish timelines for the purpose of this subsection.
(4) An insurer shall expedite an enrollee’s case if a provider with an established clinical relationship to the enrollee certifies in writing and provides supporting documentation that the ordinary time period for external review would seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. [2001 c.266 §8]Section: Previous 743.850 743.851 743.852 743.853 743.854 743.855 743.856 743.857 743.858 743.859 743.860 743.861 743.862 743.863 743.864 Next
Last modified: August 7, 2008