OAR 836-052-0140
Standards for Claims Payment


(1)

An issuer must comply with Section 1882(c)(3) of the Social Security Act, as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Public Law No. 100-203, by:

(a)

Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

(b)

Notifying the participating physician or supplier and the beneficiary of the payment determination;

(c)

Paying the participating physician or supplier directly;

(d)

Furnishing each enrollee, at the time of enrollment, with a card listing the policy name, number and a central mailing address to which notices from a Medicare carrier may be sent;

(e)

Paying user fees for claim notices that are transmitted electronically or otherwise; and

(f)

Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

(2)

Each insurer providing Medicare supplement coverage in this state shall, concurrent with the filing of the Accident and Health Policy Experience Exhibit, file a Medicare Supplement Insurance Experience Exhibit. The exhibit shall be in a format prescribed by the Director. The Director may prescribe the format adopted by the National Association of Insurance Commissioners. The following provisions also apply:

(a)

Every insurer providing Medicare supplement coverage in this state shall file with the Medicare Supplement Insurance Experience Exhibit a list of its Medicare supplement policies or certificates offered or issued and outstanding in this state as of the end of the previous calendar year;

(b)

The list under subsection (a) of this section shall identify the filing insurer by name and address, shall identify each policy or certificate by name and form number, and shall differentiate between policies and certificates filed with and approved by the Director in years prior to the previous calendar year and those filed and approved in the previous calendar year;

(c)

Policies and certificates that are issued and outstanding in this state but are no longer offered for sale shall be specifically identified, as shall any policies or certificates that for any reason were not filed with and approved by the Director;

(d)

The list shall include identification of any policy or certificate for which the Director’s approval was withdrawn within the previous calendar year;

(e)

On or before the first day of September of each year, commencing September 1, 1989, the Director shall provide the Secretary of Health and Human Services with a list containing the information required to be submitted by this section and identifying each insurer by name and address.

(3)

Compliance with the requirements set forth in this rule must be certified by the insurer on the Medicare supplement insurance experience reporting form.
[Publications: Publications referenced are available from the agency.]

Source: Rule 836-052-0140 — Standards for Claims Payment, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0140.

836–052–0103
Purpose
836–052–0107
Authority
836–052–0114
Applicability and Scope
836–052–0119
Definitions
836–052–0124
Policy Definitions and Terms
836–052–0129
Policy Provisions
836–052–0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
836–052–0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992
836–052–0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836–052–0138
Open Enrollment
836–052–0139
Medicare Select Policies and Certificates
836–052–0140
Standards for Claims Payment
836–052–0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010
836–052–0142
Guaranteed Issue for Eligible Persons
836–052–0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate
836–052–0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020.
836–052–0145
Loss Ratio Standards and Refund or Credit of Premium
836–052–0151
Filing and Approval of Policies and Certificates and Premium Rates
836–052–0156
Permitted Compensation Arrangements
836–052–0160
Required Disclosure Provisions
836–052–0165
Requirements for Application Forms, Replacement Coverage
836–052–0170
Filing Requirements for Advertising
836–052–0175
Standards for Marketing
836–052–0180
Appropriateness of Recommended Purchase and Excessive Insurance
836–052–0185
Reporting of Multiple Policies
836–052–0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing
836–052–0194
Separability
836–052–0225
Durational Limits for Health Maintenance Organizations
836–052–0230
Provider Services Limits for Insurers and Health Care Contractors
836–052–0500
Statutory Authority
836–052–0508
Definitions
836–052–0516
Policy Definitions
836–052–0526
Policy Practices and Provisions
836–052–0531
Long Term Care Insurance Partnership Program
836–052–0546
Required Policy Provisions
836–052–0556
Required Disclosure of Rating Practices to Consumers
836–052–0566
Initial Rate Filing Requirements
836–052–0576
Prohibition Against Post-Claims Underwriting, Applications
836–052–0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies
836–052–0596
Standards for Covered Services
836–052–0606
Use and Definition of “Home” or Similar Wording
836–052–0616
Requirement to Offer Inflation Protection
836–052–0626
Requirements for Application Forms and Replacement Coverage
836–052–0636
Reporting Requirements
836–052–0637
Annual Rate Certification Requirements
836–052–0639
Training for Insurance Producers
836–052–0646
Benefits Provided Through Advancement of Life Insurance Proceeds
836–052–0656
Reserve Standards
836–052–0666
Loss Ratio
836–052–0676
Premium Rate Schedule Increases
836–052–0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings
836–052–0686
Filing Requirements for Out-of-State Group Policies
836–052–0696
Filing Requirements for Advertising
836–052–0706
Standards for Marketing
836–052–0716
Disclosure Statement
836–052–0726
Suitability
836–052–0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates
836–052–0738
Availability of New Services or Providers
836–052–0740
Right to Reduce Coverage and Lower Premiums
836–052–0746
Nonforfeiture Benefit Requirement
836–052–0756
Standards for Benefit Triggers
836–052–0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts
836–052–0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met
836–052–0770
Prompt Payment of Clean Claims
836–052–0776
Standard Format Outline of Coverage
836–052–0786
Requirement to Deliver Shopper’s Guide
836–052–0790
Disclosure of Benefits Paid
836–052–0800
Purpose
836–052–0810
Replacement Upon Termination
836–052–0840
Termination of Coverage
836–052–0850
Multiple Employer Trusts
836–052–0860
Form of Notice to Group Policyholder
836–052–1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0140’s source at or​.us