Or. Admin. Code § 836-053-1330

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

Section 836-053-1330 - Criteria and Considerations for External Review Determinations

(1) The following criteria and considerations apply to decisions by an independent review organization:

(a) An independent review organization must use fair procedures in making a decision, and the decision must be consistent with the standards in ORS 743B.253 and 743B.256 and OAR 836-053-1300 to 836-053-1365.

(b) An independent review organization may override the standards of a health benefit plan governing the coverage issues that are subject to independent review pursuant to ORS 743B.252(1) only if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.

(2) A decision by an independent review organization of a dispute relating to an adverse decision by an insurer is subject to enforcement under ORS 743B.252 to 743B.258 if:

(a) The dispute relates to an adverse decision 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; or

(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 743B.225; and

(b) The decision by the independent review organization is made in accordance with the coverage described in the health benefit plan, including limitations and exclusions expressed in the 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:

(A) The standards of the insurer are unreasonable or are inconsistent with sound medical practice; or

(B) For cases in which the insurer's decision addressed whether a course or plan of treatment was medically necessary:

(i) The insurer's decision did not conform to the insurer's definition of medically necessary in the relevant health insurance policy, or

(ii) The insurer's decision did not conform to the requirement that the definition of medical necessity be uniformly applied; or

(C) For cases in which the insurer's decision addressed whether a course or plan of treatment was experimental or investigational:

(i) The insurer's decision did not conform to the insurer's definition of experimental or investigational in the relevant health insurance policy, or

(ii) The insurer's decision did not conform to the requirement that the definition of experimental or investigational be uniformly applied.

(3) No provision of OAR 836-053-1300 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action.

Or. Admin. Code § 836-053-1330

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 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 20-2018, minor correction filed 08/21/2018, effective 8/21/2018

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

Statutes/Other Implemented: ORS 743B.253, ORS 743B.225, ORS 743B.252, ORS 743B.256 & ORS 743B.258