2017 Oregon Revised Statutes
Volume : 16 - Financial Institutions, Insurance
Chapter 743B - Health Benefit Plans: Individual and Group
Section 743B.253 - Director to contract with independent review organizations to provide external review; rules.
(1) The Director of the Department of Consumer and Business Services shall contract with independent review organizations as provided in this section for the purpose of providing external review under ORS 743B.252. The director may have contracts with no more than five independent review organizations at any one time. Contracts shall be let with independent review organizations on a biennial basis. A contract may be renewed if both parties agree.
(2) The director shall seek public comment when the director proposes to enter into a contract with an independent review organization or proposes to renew or not renew a contract.
(3) When evaluating proposals to contract with independent review organizations, the director shall consider factors that include but are not limited to relative expertise, professionalism, quality of compliance with the rules established under subsection (4) of this section, cost and record of past performance.
(4) The director shall adopt rules governing independent review organizations, their composition and their conduct. The rules shall include but need not be limited to:
(a) Professional qualifications of health care providers, physicians or contract specialists making external review determinations;
(b) Criteria requiring independent review organizations to demonstrate protections against bias and conflicts of interest;
(c) Procedures for conducting external reviews;
(d) Procedures for complaint investigations;
(e) Procedures for ensuring the confidentiality of medical records transmitted to the independent review organizations for use in external reviews;
(f) Fairness of procedures used by independent review organizations;
(g) Fees for external reviews;
(h) Timelines for decision making and notice to the parties; and
(i) Quality assurance mechanisms to ensure timeliness and quality of review.
(5) The director shall develop procedures for assigning cases filed by enrollees to independent review organizations under contract with the director. The cases shall be assigned on a random basis. The procedures shall allow an insurer only one opportunity to reject the assignment of an independent review organization to a particular case. [Formerly 743.858]
