OAR 836-053-1340
Timelines and Notice for Dispute That is Not Expedited

(1) An insurer shall give the Director of the Department of Consumer and Business Services notice of an enrollee’s request for independent review by delivering a copy of the request to the director not later than the second business day of the insurer after the insurer receives the request for the independent review. In the event the enrollee applies to the director rather than to the insurer for independent review, the director shall provide the insurer notice of the enrollee’s request for independent review by delivering a copy of the request to the insurer not later than the next business day of the department after the director receives the request for independent review.
(2) If an insurer reverses its final adverse determination before expiration of the deadline for sending the notice to the director under section (1) of this rule, the insurer must notify the enrollee not later than the next business day of the insurer after the insurer’s reversal. The notice to the enrollee may be given by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the insurer.
(3) Not later than the next business day of the department after the director has received a request for independent review from an insurer or an enrollee, the director shall assign the review to one of the independent review organizations with whom the director has contracted. The director shall notify the insurer in writing of the name and address of the independent review organization to which the request for the independent review should be sent. If sending written notice will unduly delay notification, the director shall give the notice by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the department.
(4) The director shall notify the enrollee of the assignment of the request, not later than the second business day of the department after the director gave notice under section (3) of this rule. The notice must include a written description of the independent review organization selected to conduct the independent review and information explaining how the enrollee may provide the director with documentation regarding any potential conflict of interest of the independent review organization as described in OAR 836-053-1320 (Conflict of Interest).
(5) Not later than the third calendar day following receipt of notice from the director under section (4) of this rule, or the subsequent business day of the department if any of the days is not a normal business day of the department, the enrollee may provide the director with documentation in writing regarding a potential conflict of interest of the independent review organization. If sending written documentation will unduly delay the process, the enrollee shall give the notice by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the department. If the director determines that the independent review organization presents a conflict of interest as described in OAR 836-053-1320 (Conflict of Interest), the director shall assign another independent review organization not later than the next business day of the department. The director shall notify the insurer of the new independent review organization to which the request for the independent review should be sent. The director shall also notify the enrollee of the director’s determination regarding the potential conflict of interest and the name and address of the new independent review organization.
(6) Not later than the fifth business day of the insurer after the date on which the insurer received notice from the director under section (3) of this rule, the insurer shall deliver to the assigned independent review organization the following documents and information considered in making the insurer’s final adverse decision, including the following:
(a) Information submitted to the insurer by a provider or the enrollee in support of the request for coverage under the health benefit plan’s procedures.
(b) Information used by the health benefit plan during the internal appeal process to determine whether the course or plan of treatment is:
(A) Medically necessary;
(B) Experimental or investigational; or
(C) An active course of treatment for purposes of continuity of care.
(c) A copy of all denial letters issued by the plan concerning the case under review.
(d) A copy of the signed waiver form, or a waiver, authorization or consent that is otherwise permitted under the federal Health Insurance Portability and Accountability Act or other state or federal law, authorizing the insurer to disclose protected health information, including medical records, concerning the enrollee that is pertinent to the independent review.
(e) An index of all submitted documents.
(7) Not later than the second business day of the independent review organization after receiving the material specified in section (6) of this rule, the independent review organization shall deliver to the enrollee the index of all materials that the insurer has submitted to the independent review organization. Upon request of the enrollee, the independent review organization shall provide to the enrollee all relevant information supplied to the independent review organization that is not confidential or privileged under state or federal law concerning the case under review.
(8) After receipt of the notice from the director under section (4) of this rule, the enrollee, the insurer or a provider acting on behalf of the enrollee or at the enrollee’s request may submit additional information to the independent review organization. In accordance with OAR 836-053-1325 (Procedures for Conducting External Reviews)(4)(b) the independent review organization must consider this additional information if the information is related to the case and relevant to the statutory criteria for external review contained in ORS 743B.252 (External review). The independent review organization is not required to consider this information if the information is submitted after the fifth business day of the independent review organization following the enrollee’s receipt of notice from the director under section (4) of this rule. Upon receiving information under this section the independent review organization must:
(a) Forward any information provided by the insurer to the enrollee within one business day after the independent review organization receives the information; and
(b) Forward any information provided by the enrollee or a provider acting on behalf of the enrollee or at the enrollee’s request to the insurer within one business day after the independent review organization receives the information.
(9) The independent review organization shall notify the enrollee, the provider of the enrollee and the insurer of any additional medical information required to conduct the review after receipt of the documentation under section (7) of this rule. Not later than the fifth business day after such a request, the enrollee or the provider of the enrollee shall submit to the independent review organization the additional information or an explanation of why the additional information is not being submitted. If the enrollee or the provider of the enrollee fails to provide the additional information or the explanation of why additional information is not being submitted within the timeline specified in this subsection, the assigned independent review organization shall make a decision based on the information submitted by the insurer as required by section (6) of this rule. Except as provided in this section, failure by the insurer to provide the documents and information within the time specified in section (6) of this rule shall not delay the external review.
(10) An independent review organization must provide notice to enrollees and the insurer of the result and basis for the decision as provided in OAR 836-053-1325 (Procedures for Conducting External Reviews) not later than the fifth day after the independent review organization makes a decision in a non-expedited case.

Source: Rule 836-053-1340 — Timelines and Notice for Dispute That is Not Expedited, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-1340.

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 836-053-1340’s source at or​.us