71st OREGON LEGISLATIVE ASSEMBLY--2001 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 2737
Senate Bill 812
Sponsored by Senator FISHER (at the request of Health Insurance
Association of America)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires Department of Human Services and health insurance
carriers to pay claims in timely manner.
A BILL FOR AN ACT
Relating to payment of claims.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2001 Act is added to and made
a part of ORS chapter 414. + }
SECTION 2. { + (1) As used in this section:
(a) 'Claim' includes a clean claim and a health insurance
claim.
(b) 'Clean claim' means a claim for payment of medical and
remedial care and services that:
(A) Is submitted to the Department of Human Services by a
provider;
(B) Is eligible for reimbursement under the terms and
conditions of a fee-for-service payment system;
(C) Has no defect or impropriety, including a lack of any
required substantiating documentation; and
(D) Has no particular circumstances requiring special treatment
that prevents timely payment from being made.
(c) 'Health insurance claim' means a claim for payment of
medical and remedial care and services that is submitted to the
department and that is not a clean claim.
(d) 'Provider' has the meaning given that term in ORS 743.801.
(2) The Department of Human Services shall pay a provider that
provides medical and remedial care and services that are
reimbursable under ORS 414.705 under a fee-for-service payment
system according to the following payment schedule:
(a) The department shall pay a clean claim within 30 days of
receipt of the claim.
(b) If the department needs additional information on a health
insurance claim, the department must request the additional
information in writing within 30 days of receipt of the claim.
(c) The department shall pay or deny a health insurance claim
within 30 days of receipt of the requested information under
paragraph (b) of this subsection, or notify the provider that
additional information is necessary to pay the claim.
(d) If the department denies a claim, the department shall
notify the provider in writing within 30 days of receipt of the
claim or requested information under paragraph (b) of this
subsection, citing the policy, provision, condition or exclusion
that is the basis of the denial.
(3) A provider that receives a request for additional
information under subsection (2) of this section shall respond to
the request within 30 days of receipt of the request.
(4) Nothing in this section shall be construed as prohibiting
the department and a provider from mutually agreeing to payment
provisions other than those described in subsection (2) of this
section.
(5)(a) Subsection (2) of this section does not apply to a claim
that:
(A) Is pending due to information that must be provided by the
person receiving medical assistance, as defined in ORS 414.025;
(B) Is being investigated for errors and omissions;
(C) Is being investigated for fraud and abuse;
(D) Is under utilization review or review of medical necessity;
or
(E) Is pending due to a discrepancy in the codes submitted for
the transaction.
(b) The department shall notify a provider in writing of the
pending status of a claim within 30 days of receipt of the claim
with an explanation of the reason for the pending status of the
claim.
(6) Subsection (2) of this section applies to claims filed
within 30 days from the earliest date of services noted on the
claim.
(7) A provider may not file a duplicate electronic claim within
60 days of the initial filing of the claim or within 90 days of
the initial filing of a paper claim unless the provider receives
a request from the department to refile the claim. + }
SECTION 3. { + The Department of Human Services may adopt
rules necessary for the implementation of section 2 of this 2001
Act. + }
SECTION 4. { + Section 5 of this 2001 Act is added to and made
a part of ORS chapter 743. + }
SECTION 5. { + (1) As used in this section:
(a) 'Carrier' has the meaning given that term in ORS 743.730.
(b) 'Claim' includes a clean claim and a health insurance
claim.
(c) 'Clean claim' means a claim for payment of health care
services that:
(A) Is submitted to a carrier by a provider for services that
are eligible for reimbursement under the terms and conditions of
the health benefit plan;
(B) Has no defect or impropriety, including a lack of any
required substantiating documentation; and
(C) Has no particular circumstances requiring special treatment
that prevents timely payment from being made.
(d) 'Enrollee' has the meaning given that term in ORS 743.730.
(e) 'Health benefit plan' has the meaning given that term in
ORS 743.730.
(f) 'Health care services' has the meaning given that term in
ORS 750.005.
(g) 'Health insurance claim' means a claim for payment of
health care services that is submitted to a carrier and that is
not a clean claim.
(h) 'Provider' has the meaning given that term in ORS 743.801.
(2) A contract between a carrier and a provider shall contain
the provisions for payment of claims under the contract.
(3) A carrier must pay a clean claim within 30 days of receipt
of the claim or within the time period specified in the contract.
(4) If a carrier needs additional information to process a
health insurance claim, the carrier must request the additional
information in writing within 30 days of receipt of the claim.
(5) A provider who receives a request under subsection (4) of
this section must provide the additional information to the
carrier within 30 days of receipt of the request if the provider
has access to the information.
(6)(a) A carrier shall pay, deny or settle a health insurance
claim within 30 days of receipt of the requested additional
information under subsection (4) of this section.
(b) If the carrier still needs additional information on the
claim, the carrier shall notify the provider every 30 days
specifying the additional information that is necessary.
(7) If a carrier denies a claim, the carrier shall notify the
provider in writing within 30 days of receipt of the claim or
requested additional information, citing the specific policy or
contract provision, condition or exclusion that is the basis of
the denial.
(8) Subsections (3) to (7) of this section do not apply to a
claim that:
(a) Is pending due to information that must be provided by an
enrollee or other party;
(b) Is being investigated for errors and omissions;
(c) Is being investigated for fraud and abuse;
(d) Is under utilization review or review of medical necessity;
(e) Is pending due to a discrepancy in the codes submitted for
the transaction; or
(f) Is paid under a capitated agreement on a periodic basis by
mutual agreement between a carrier and a provider.
(9) Nothing in this section shall be construed as prohibiting a
carrier and a provider from mutually agreeing to payment
provisions other than those contained in subsections (3) to (7)
of this section. + }
SECTION 6. { + Section 5 of this 2001 Act applies to claims
filed by providers within 30 days of the date of service. A
provider may not file a duplicate electronic claim within 60 days
of the initial filing of the claim or within 90 days of the
initial filing of a nonelectronic claim. + }
SECTION 7. { + Section 5 of this 2001 Act does not apply to
claims that are subject to payment through the coordination of
benefits under ORS 743.549, coverage of Medicare services or
coverage of services arising out of workers' compensation
laws. + }
SECTION 8. { + The Department of Consumer and Business
Services may adopt rules necessary for the implementation of
section 5 of this 2001 Act. + }
SECTION 9. { + Sections 2 and 5 of this 2001 Act apply to
claims submitted to the Department of Human Services or a carrier
on or after the effective date of this 2001 Act. + }
----------