Or. Admin. Code § 836-053-1410

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

Section 836-053-1410 - Procedures

(1) An insurer shall allocate covered procedures or services to the categories established in ORS 743.874(3) and 743.876(3) in a manner that will enable the insurer to provide a reasonable estimate of an enrollee's share of costs for a procedure or service. An insurer shall determine its allocation according to its Oregon block of business at least once every 12 months to ensure that the procedures and services are currently the most common procedures in the categories.

(2) When an insurer must provide to an enrollee a combined estimate for two or more procedures or services, the insurer shall apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. The insurer must disclose to the enrollee, along with an estimate under this section, that the estimate includes the costs of two or more procedures or services.

(3) An insurer shall disclose with an estimate whether the estimate applies only to those costs specifically relating to the procedure or service, such as is given in commonly used procedure codes, or applies to an episode of care that includes the procedure or service and its related costs.

(4) An insurer shall file with the Director, as required by the Director, the following information for the purpose of assessing the effect of the disclosure requirements in ORS 743.874 and 743.876:

(a) The number of requests for estimates under ORS 743.874 and 743.876, received by the insurer in a calendar year; and

(b) Of the requests in paragraph (a) of this subsection, the number of requests for in-network procedures and services and the number of requests for out-of-network procedures.

Or. Admin. Code § 836-053-1410

ID 16-2008, f. & cert. ef. 9-24-08

Stat. Auth.: ORS 731.244 & 743.893

Stats. Implemented: ORS 743.874, 743.876 & 743.878