2017 Oregon Revised Statutes
Volume : 16 - Financial Institutions, Insurance
Chapter 743B - Health Benefit Plans: Individual and Group
Section 743B.451 - Refund of paid claims.
(1) As used in this section, "refund" means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider.
(2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not:
(a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer:
(A) Requests the refund in writing on or before the last day of the period specified by the contract with the health care provider or 18 months after the date the payment was made, whichever is earlier; and
(B) Specifies in the written request why the health insurer believes the provider owes the refund.
(b) Request that a contested refund be paid earlier than six months after the health care provider receives the request.
(3) A health insurer may not do the following for reasons related to coordination of benefits with another health insurer or entity responsible for payment of a claim:
(a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer:
(A) Requests the refund in writing within 30 months after the date the payment was made;
(B) Specifies in the written request why the health insurer believes the provider owes the refund; and
(C) Includes in the written request the name and mailing address of the other health insurer or entity that has primary responsibility for payment of the claim.
(b) Request that a contested refund be paid earlier than six months after the provider receives the request.
(4) If a health care provider fails to contest a refund request in writing to the health insurer within 30 days after receiving the request, the request is deemed accepted and the provider must pay the refund within 30 days after the request is deemed accepted. If the provider has not paid the refund within 30 days after the request is deemed accepted, the health insurer may recover the amount through an offset to a future claim.
(5) A health insurer may at any time request from a health care provider a refund of a payment previously made to satisfy a claim if:
(a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law; and
(b) The health insurer is unable to recover directly from the third party because the third party has already paid or will pay the provider for the health care services covered by the claim.
(6) If a contract between a health insurer and a health care provider conflicts with this section, the provisions of this section prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a health insurer any payment previously made to satisfy a claim.
(7) This section neither permits nor precludes a health insurer from recovering from a subscriber, enrollee or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy or other benefit agreement.
(8) This section applies to health benefit plans. [Formerly 743.912]
Note: 743B.451 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
