(1) An independent review organization shall perform the following duties when appointed under ORS 743.857 to review a dispute under a health benefit plan between an insurer and an enrollee:
(a) Decide whether the dispute is covered by the conditions established in ORS 743.857 for external review and notify the enrollee and insurer in writing of the decision. If the decision is against the enrollee, the independent review organization shall notify the enrollee of the right to file a complaint with or seek other assistance from the Director of the Department of Consumer and Business Services and the availability of other assistance as specified by the director.
(b) Appoint a reviewer or reviewers as determined appropriate by the independent review organization.
(c) Notify the enrollee of information that the enrollee is required to provide and any additional information the enrollee may provide, and when the information must be submitted.
(d) Notify the insurer of additional information the independent review organization requires and when the information must be submitted.
(e) Decide the dispute relating to the adverse decision of the insurer under ORS 743.857 (1) and issue the decision in writing.
(2) A decision by an independent review organization shall be based on expert medical judgment after consideration of the enrollee’s medical record, the recommendations of each of the enrollee’s providers, relevant medical, scientific and cost-effectiveness evidence and standards of medical practice in the United States. An independent review organization must make its decision in accordance with the coverage described in the health benefit plan, except that the independent review organization may override the insurer’s standards for medically necessary or experimental or investigational treatment if the independent review organization determines that the standards of the insurer are unreasonable or are inconsistent with sound medical practice.
(3) When review is expedited, the independent review organization shall issue a decision not later than the third day after the date on which the enrollee applies to the insurer for an expedited review.
(4) When a review is not expedited, the independent review organization shall issue a decision not later than the 30th day after the enrollee applies to the insurer for a review.
(5) An independent review organization shall file synopses of its decisions with the director according to the format and other requirements established by the director. The synopses shall exclude information that is confidential, that is otherwise exempt from disclosure under ORS 192.501 and 192.502 or that may otherwise allow identification of an enrollee. The director shall make the synopses public. [2001 c.266 §12]
Section: Previous 743.855 743.856 743.857 743.858 743.859 743.860 743.861 743.862 743.863 743.864 743.865 743.866 743.868 743.870 743.871 NextLast modified: August 7, 2008