OAR 836-053-1200
Prior Authorization Requirements for Health Benefit Plans

(1)

The provisions of this rule implement the requirements of ORS 743B.420 (Prior authorization requirements) and the amendments to ORS 743B.422 (Utilization review requirements for medical services contracts to which insurer not party) and ORS 743B.423 (Utilization review requirements for insurers offering health benefit plan) by Oregon Laws 2019, chapter 284 relating to prior authorization determinations. “Prior authorization” means a determination by an insurer, prior to provision of health care that is subject to utilization review, that the insurer will provide reimbursement for the health care requested. “Prior authorization” does not include referral approval for evaluation and management services between providers. For the purposes of this rule, “health care” includes all items and services covered by a health benefit plan, including but not limited to medical, behavioral health, dental and vision care items and services.

(2)

This rule applies to prior authorization determinations that:

(a)

Are issued orally or in writing by an insurer to a provider or enrollee regarding the benefit coverage or medical necessity of a health care item or service to be provided to an enrollee; and

(b)

Are required under and obtained in accordance with the terms of a health benefit plan.

(3)

A prior authorization may be limited to the services of a specific provider or to services of a designated group of providers who contract with or are employed by the insurer.

(4)

Nothing in this rule shall require a health benefit plan to contain a prior authorization requirement.

(5)

Except in the case of misrepresentation relevant to a request for prior authorization, a prior authorization determination shall be binding on the insurer for the period of time specified in section (6) of this rule.

(6)

A prior authorization determination shall be binding on the insurer for:

(a)

The lesser of the following periods:

(A)

Five business days following the date of issuance of the authorization; or

(B)

The period during which the enrollee’s coverage remains in effect, provided that when the insurer issues the prior authorization, the insurer has specific knowledge that the enrollee’s coverage will terminate sooner than five business days following the day the authorization is issued and the insurer specifies the termination date in the authorization; and

(b)

The period during which the enrollee’s coverage remains in effect beyond the time period established pursuant to subsection (a) of this section, up to a maximum of 30 calendar days.

(7)

For purposes of counting days under section (6) of this rule, day one is the first business or calendar day, as applicable, following the day on which the insurer issues a prior authorization determination.

(8)

An insurer may not impose a restriction or condition on its prior authorization determinations that limits, restricts or effectively eliminates the binding force established for such determinations in ORS 743B.420 (Prior authorization requirements) and this rule.

(9)

A prior authorization determination is issued when an insurer communicates orally, or in writing, a notice that meets the requirements of section (11) of this rule to the provider or enrollee who submitted the prior authorization request.

(10)

Except as provided in section (13), a determination by an insurer on a provider’s or an enrollee’s request for prior authorization must be issued within a reasonable period of time appropriate to the medical circumstances but no later than two business days after receipt of the request. If the determination is issued orally, the insurer must mail, or send electronically, a written notice of the determination to the provider or enrollee who submitted the prior authorization request no later than two business days after the determination is issued. For the purposes of counting days under this subsection, day one is the first business day following the day on which the insurer receives the request for prior authorization or issues the determination, as applicable.

(11)

When an insurer issues a determination in response to a request from a provider or an enrollee for prior authorization of nonemergency health care items or services, the determination must be one of the following:

(a)

The requested item or service is authorized;

(b)

The requested item or service is not authorized; or

(c)

The entire requested item or service is not authorized, but a specified portion of the requested item or service or a specified alternative item or service is authorized.

(12)

If an insurer makes a determination meeting the conditions specified in subsections (b) or (c) of section (11), the notice of that determination must be mailed, or sent electronically, to the enrollee who is the subject of the prior authorization request, regardless of whether the enrollee submitted the prior authorization request to the insurer. The notice must specify that the determination constitutes an adverse benefit determination, and that the enrollee has the right to appeal the determination, and to external review of the determination if applicable.

(13)

If additional information from an enrollee or a provider requesting prior authorization is necessary to make a determination on a request for prior authorization, no later than two business days after receipt of the request, the enrollee and the requesting provider, if any, shall be notified in writing of the specific additional information needed to make the determination. The required notice is provided when it is mailed, or delivered electronically, by the insurer. For the purposes of counting days under this subsection, day one is the first business day following the day on which the insurer receives the request for prior authorization. Nothing in this subsection shall be construed to prohibit an insurer from seeking additional information related to a prior authorization request orally or by other means, provided that a written notice is supplied in the event that a determination cannot be made within two business days due to the need for additional information.

(14)

Following a request for additional information submitted in compliance with section (13), the insurer must issue a determination by the later of:

(a)

Two business days after receipt of a response to the request for additional information. For the purposes of counting days under this subsection, day one is the first business day following the day on which the insurer receives a response; or,

(b)

Fifteen days after the date of the request for additional information, unless otherwise provided in federal law. For the purposes of counting days under this subsection, day one is the first calendar day following the day on which the insurer mails, or sends electronically, the request for additional information.

(15)

When an insurer requests additional information that is necessary to make a determination on a request for prior authorization, the insurer must specify all of the information reasonably necessary to make a determination. The insurer may not request information that is substantially identical to information previously supplied by the enrollee or provider.

(16)

Compliance with this rule by an insurer offering a health benefit plan will be sufficient to demonstrate compliance with the requirement for insurers to act promptly in making determinations in response to requests for prior authorization established by Oregon Laws 2019, chapter 284, section 2(2)(e). Nothing in this rule shall be construed to limit the department’s authority under this section to require a health insurer to act equitably and in good faith with respect to approving requests for prior authorization.

Source: Rule 836-053-1200 — Prior Authorization Requirements for Health Benefit Plans, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-1200.

836–053–0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 836–053–0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 836–053–0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 836–053–0003
Prohibition of Exclusion Period for Pregnancy 836–053–0004
Compliance with Federal and State Law 836–053–0005
Prescription Drug Identification Cards 836–053–0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 836–053–0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016 836–053–0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 836–053–0011
Standard Bronze Plan Health Savings Account Eligible Requirement 836–053–0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 836–053–0013
Oregon Standard Bronze and Silver Health Benefit Plans 836–053–0014
Standards and Process for Shortened Period of Market Prohibition 836–053–0015
Definition of Small Employer 836–053–0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 836–053–0019
Purpose 836–053–0021
Plans Offered to Oregon Small Employers 836–053–0030
Marketing of a Health Benefit Plan to Small Employers 836–053–0050
Trade Practices Relating to Small Employer Health Benefit Plans 836–053–0063
Rating for Nongrandfathered Small Group Plans 836–053–0065
Rating for Grandfathered Small Group Plans 836–053–0066
Rating for Transitional Health Benefit Plans Offered to Small Employers 836–053–0070
Multiple Employer Welfare Arrangements 836–053–0100
Work Related Injuries or Disease 836–053–0105
Coordination of Payment for Interim Medical Services 836–053–0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 836–053–0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 836–053–0230
Underwriting 836–053–0300
Purpose 836–053–0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350 836–053–0320
Annual Report Requirements for Network Adequacy 836–053–0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements 836–053–0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements 836–053–0350
Provider Directory Requirements for Network Adequacy 836–053–0410
Purpose 836–053–0415
Cancellation of an Individual Health Benefit Plan Coverage 836–053–0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 836–053–0431
Underwriting, Enrollment and Benefit Design 836–053–0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services 836–053–0465
Rating for Individual Health Benefit Plans 836–053–0472
Statutory Authority and Implementation 836–053–0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 836–053–0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans 836–053–0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 836–053–0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 836–053–0600
Purpose 836–053–0605
Definitions for OAR 836-053-0600 to 836-053-0615 836–053–0610
Carrier Response to Request for Confidentiality 836–053–0615
Carrier Reporting Requirements 836–053–0825
Rescission of a Group Health Benefit Plan 836–053–0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 836–053–0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 836–053–0851
Purpose 836–053–0857
Definitions 836–053–0863
Notifications 836–053–0900
Purpose 836–053–0910
Rate Filing 836–053–1000
Statutory Authority and Implementation 836–053–1010
Insurer Policies 836–053–1020
Drug Formularies 836–053–1030
Written Information to Enrollees 836–053–1033
Cultural and Linguistic Appropriateness 836–053–1035
Summary of Benefits and Explanation of Coverage 836–053–1060
Definitions 836–053–1070
Reporting of Grievances 836–053–1080
Tracking Grievances 836–053–1090
Assistance in Filing Grievances 836–053–1100
Internal Appeals Process 836–053–1110
Notice of Complaint Filing with Director 836–053–1130
Annual Summary, Utilization Review 836–053–1140
Appeal and Utilization Review Determinations 836–053–1170
Annual Summary, Quality Assessment Activities 836–053–1180
Format and Instructions for Report Required by ORS 743.818 836–053–1190
Annual Summary, Uniform Indicators of Network Adequacy 836–053–1200
Prior Authorization Requirements for Health Benefit Plans 836–053–1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 836–053–1205
Uniform Prescription Drug Prior Authorization Request Form 836–053–1300
Purpose and Scope 836–053–1305
Definitions 836–053–1310
Contracting Requirements 836–053–1315
Performance Criteria 836–053–1317
Professional Qualifications 836–053–1320
Conflict of Interest 836–053–1325
Procedures for Conducting External Reviews 836–053–1330
Criteria and Considerations for External Review Determinations 836–053–1335
Procedures for Complaint Investigation 836–053–1337
Preliminary Review by Insurer 836–053–1340
Timelines and Notice for Dispute That is Not Expedited 836–053–1342
Timelines and Notice for Expedited Decision-Making 836–053–1345
Quality Assurance Mechanisms 836–053–1350
Ongoing Requirements for Independent Review Organizations 836–053–1355
Synopses 836–053–1360
External Review Reporting 836–053–1365
Fees for External Reviews 836–053–1400
Format and Instructions for Report Required by ORS 743.748 836–053–1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 836–053–1404
Definitions 836–053–1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency 836–053–1407
Prohibited Exclusions 836–053–1408
Required Disclosures 836–053–1409
Definitions 836–053–1410
Procedures 836–053–1415
Instructions 836–053–1500
Purpose 836–053–1505
Definitions for OAR 836-053-1500 to 836-053-1510 836–053–1510
Prominent Carrier Reporting Requirements 836–053–1520
Purpose 836–053–1525
Definitions 836–053–1530
Reporting Requirements 836–053–1600
Purpose 836–053–1605
Definitions for 836-053-1600 to 836-053-1615 836–053–1610
Non-anesthesia-related claims 836–053–1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-1200’s source at or​.us