Or. Admin. Code § 836-053-1315

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1315 - Performance Criteria

The following are performance criteria that an independent review organization must satisfy when demonstrating its eligibility for contracting with the Director of the Department of Consumer and Business Services to perform independent review responsibilities under ORS 743B.256, and in order to continue performing those responsibilities under the contract with the director. For purposes of this rule, an independent review organization must:

(1) Demonstrate its capability of and expertise in reviewing health care, and a history of such review, in terms of the coverage issues that are subject to independent review pursuant to ORS 743B.252, in terms of the application of other health plan coverage provisions and in terms of health insurance contract law.

(2) Demonstrate the ability to handle a full range of review cases occurring in this state. An independent review organization may contract with a more specialized review organization, but the independent review organization must ensure that each review conducted meets all the requirements of ORS 743B.252, 743B.253 and 743B.256 and OAR 836-053-1300 to 836-053-1365.

(3) Comply with all conflict of interest provisions in OAR 836-053-1320.

(4) Maintain and assign an adequate number and range of qualified medical reviewers in compliance with OAR 836-053-1310 and 836-053-1315 in order to:

(a) Make determinations regarding the full range of independent review cases occurring in this state under ORS 743B.252; and

(b) Meet timelines specified in ORS 743B.256 and OAR 836-053-1340, including timelines for expedited review.

(5) Conduct reviews, reach determinations and document determinations consistent with OAR 836-053-1325 and 836-053-1330.

(6) Maintain administrative processes and capabilities in compliance with OAR 836-053-1325 and 836-053-1330.

Or. Admin. Code § 836-053-1315

ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 16-2018, minor correction filed 08/20/2018, effective 8/20/2018

Statutory/Other Authority: ORS 731.244, ORS 743B.256 & ORS 743B.253

Statutes/Other Implemented: ORS 743B.256 & ORS 743B.253