OAR 836-080-0080
Definition, Claims Handling Services; Claims Procedures and Information

(1)

As used in ORS 743.911 and 743.913:

(a)

“Clean claim” means a claim under a health benefit plan that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment.

(b)

“Clean claim does not mean a claim pended under 45 CFR 156.270 (Discharge of defendant upon finding the defendant not guilty)(d)(1).

(2)

For purposes of ORS 743.911 and 743.913, an insurer is considered to have received a claim when the claim is received by the insurer itself or when the claim is received by a representative of the insurer that performs claims handling on the sole behalf of the insurer, whichever receipt date is earlier. A representative may include but is not limited to a third party administrator, a claims service or a pricing service.

(3)

For the purpose of communicating the information necessary for claim form completion as required by ORS 743.911(3), an insurer must include any specific description of standard supporting documentation, information and data routinely required to be submitted with a claim form. Compliance with the standard transaction requirements established under the federal Health Insurance Portability and Accountability Act at 45 CFR parts 160 and 162 or OAR 836-100-0105 (Definitions) and 836-100-0110 (Adoption of Standards) constitutes compliance with this section.

Source: Rule 836-080-0080 — Definition, Claims Handling Services; Claims Procedures and Information, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-080-0080.

836‑080‑0001
Statutory Authority 836‑080‑0005
Definitions 836‑080‑0014
Duties of Agent 836‑080‑0022
Duties of Insurers that Use Agents Insurance Producers 836‑080‑0029
Duties of Replacing Insurers that Use Agents 836‑080‑0034
Duties of the Existing Insurer 836‑080‑0039
Duties of Insurers with Respect to Direct Response Solicitations 836‑080‑0043
Violations and Penalties 836‑080‑0050
Authority 836‑080‑0055
Unfair Discrimination Identified 836‑080‑0080
Definition, Claims Handling Services 836‑080‑0085
Annual Report 836‑080‑0090
Suitability in the Sale of Life Insurance 836‑080‑0105
Statutory Authority 836‑080‑0110
Applicability 836‑080‑0115
Definitions 836‑080‑0120
Statement as to Participation Required Upon Request Before Delivery of Policy 836‑080‑0125
Prohibited Representations Regarding Participation Rights 836‑080‑0130
Dividend Statement Permitted 836‑080‑0135
Dividend Rights Accrue Upon Declaration of Dividends 836‑080‑0140
Unfair Discrimination in Allocation of Dividends Prohibited 836‑080‑0145
Unfair Forfeiture of Dividend for Failure to Renew Prohibited 836‑080‑0150
Policyholder Dividend Rights of Group Members and Dividend Group Policyholders 836‑080‑0155
False or Deceptive Publications by Insurer Prohibited 836‑080‑0160
Use of Special Certifications and Professional Designations by Insurance Producers 836‑080‑0165
Notice of Insurance Division Assistance 836‑080‑0170
Statutory Authority 836‑080‑0172
Applicability 836‑080‑0175
Exemptions 836‑080‑0178
Definitions 836‑080‑0180
Duties of Insurers and of Insurance Producers 836‑080‑0183
Insurance Producer Training 836‑080‑0185
Compliance Mitigation 836‑080‑0188
Recordkeeping 836‑080‑0190
Annuity Sales 836‑080‑0193
Effective Date and Operative Date 836‑080‑0200
Electronic Payment of Claims 836‑080‑0205
Statutory Authority, Purpose, and Applicability 836‑080‑0210
Definitions 836‑080‑0215
Claim Files 836‑080‑0220
Misrepresentation and Other Prohibited Claim Practices 836‑080‑0225
Required Claim Communication Practices 836‑080‑0230
Standard for Prompt Claim Investigation 836‑080‑0235
Standards for Prompt and Fair Settlements — Generally 836‑080‑0240
Standards for Prompt and Fair Total Loss Settlements — Automobile Insurance 836‑080‑0250
Workers’ Compensation Insurance Unfair Claim Settlement Practices Standards 836‑080‑0305
Statutory Authority 836‑080‑0310
Definitions 836‑080‑0315
Providing Things of Value to Intermediaries Generally Prohibited 836‑080‑0320
Miscellaneous Things of Value 836‑080‑0325
Business Development Activities 836‑080‑0335
Gifts 836‑080‑0337
Real Property Information 836‑080‑0340
Assistance in Qualifying a Subdivision 836‑080‑0345
Automatic Change in Monetary Limits 836‑080‑0355
Title Insurer Responsible for Violations by Agent 836‑080‑0360
Use by Title Company of an Intermediary’s Office 836‑080‑0365
Filing Escrow Rates Required 836‑080‑0370
Instruction of Title Company Employees About Rules Required 836‑080‑0425
Applicability 836‑080‑0430
Disclosure of Use of Credit History or Insurance Scores 836‑080‑0435
Policies Governing Credit Histories and Insurance Scores 836‑080‑0436
Absence of or Inability to Determine Credit History 836‑080‑0438
Definition of Adverse Underwriting Decision 836‑080‑0440
Unfair Insurance Trade Practice 836‑080‑0501
Authority 836‑080‑0506
Definitions and Examples 836‑080‑0511
Application of Notice Requirements 836‑080‑0516
Initial Notice to Consumers 836‑080‑0519
Information to be Included in Initial Privacy Notice 836‑080‑0523
Annual Notice 836‑080‑0526
Information to be Included in Annual Notice 836‑080‑0531
Revised Privacy Notices 836‑080‑0536
Delivery 836‑080‑0541
Opt in Notice 836‑080‑0546
Limits on Sharing Account Number Information for Marketing Purposes 836‑080‑0551
Authorization Request Delivery 836‑080‑0600
Authority 836‑080‑0610
Definitions and Examples 836‑080‑0615
Personal Information Notice 836‑080‑0620
Notice of Personal Financial Information Practices 836‑080‑0625
Alternative Procedures 836‑080‑0630
Application of Notice Requirements 836‑080‑0635
Initial Notice to Consumers 836‑080‑0640
Information to Be Included in Initial Privacy Notice 836‑080‑0645
Annual Notice 836‑080‑0650
Information to Be Included in Annual Notice 836‑080‑0655
Revised Privacy Notices 836‑080‑0660
Delivery 836‑080‑0665
Authorization 836‑080‑0670
Authorization Exemptions 836‑080‑0675
Disclosure Without Authorization 836‑080‑0680
Opt in Notice 836‑080‑0685
Limits on Sharing Account Number Information for Marketing Purposes 836‑080‑0690
Authorization Request Delivery 836‑080‑0695
Access to Recorded Personal Information 836‑080‑0700
Correction, Amendment or Deletion of Recorded Personal Information 836‑080‑0750
Purpose 836‑080‑0755
Application of OAR 836-080-0750 to 836-080-0775 836‑080‑0760
Definitions for OAR 836-080-0750 to 836-080-0775 836‑080‑0765
Practices Declared False, Misleading, Deceptive or Unfair on a Military Installation 836‑080‑0770
Practices Declared False, Misleading, Deceptive or Unfair, Regardless of Location 836‑080‑0775
Severability 836‑080‑0800
Definitions 836‑080‑0805
Statutory Authority, Purpose, and Applicability 836‑080‑0810
Provision of Commercial Loss Runs
Last Updated

Jun. 8, 2021

Rule 836-080-0080’s source at or​.us