71st OREGON LEGISLATIVE ASSEMBLY--2001 Regular Session
Enrolled
Senate Bill 894
Sponsored by Senators BURDICK, GEORGE; Senators BROWN, CARTER,
CASTILLO, CLARNO, MINNIS, Representatives BARNHART, BATES,
KNOPP, KROPF, KRUMMEL, MONNES ANDERSON, PATRIDGE, STARR, TOMEI,
C WALKER, V WALKER, WESTLUND, WINTERS, ZAUNER (at the request
of Oregon Association of Orthopaedists and Oregon Medical
Association)
CHAPTER ................
AN ACT
Relating to claims for payment of health care services; creating
new provisions; amending ORS 743.801 and 750.055; and declaring
an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Sections 2 and 3 of this 2001 Act are added to
and made a part of ORS chapter 743. + }
SECTION 2. { + (1) Except as provided in this subsection, when
a claim under a health benefit plan is submitted to an insurer by
a provider on behalf of an enrollee, the insurer shall pay a
clean claim or deny the claim not later than 30 days after the
date on which the insurer receives the claim. If an insurer
requires additional information before payment of a claim, not
later than 30 days after the date on which the insurer receives
the claim, the insurer shall notify the enrollee and the provider
in writing and give the enrollee and the provider an explanation
of the additional information needed to process the claim. The
insurer shall pay a clean claim or deny the claim not later than
30 days after the date on which the insurer receives the
additional information.
(2) A contract between an insurer and a provider may not
include a provision governing payment of claims that limits the
rights and remedies available to a provider under this section
and section 3 of this 2001 Act or has the effect of relieving
either party of their obligations under this section and section
3 of this 2001 Act.
(3) An insurer shall establish a method of communicating to
providers the procedures and information necessary to complete
claim forms. The procedures and information must be reasonably
accessible to providers.
(4) This section does not create an assignment of payment to a
provider.
(5) Each insurer shall report to the Director of the Department
of Consumer and Business Services annually on its compliance
under this section according to requirements established by the
director.
(6) The director shall adopt by rule a definition of 'clean
claim' and shall consider the definition of 'clean claim' used by
Enrolled Senate Bill 894 (SB 894-A) Page 1
the federal Department of Health and Human Services for the
payment of Medicare claims. + }
SECTION 3. { + (1) An insurer that fails to pay a claim to a
provider within the timelines established in section 2 of this
2001 Act shall pay simple interest of 12 percent per annum on the
unpaid amount of the claim that is due and owing, accruing from
the date after the payment was due until the claim is paid.
Interest on any overdue payment for a claim begins to accrue + }
{ + on the 31st day after:
(a) The date on which the insurer received the claim; or
(b) The date the insurer receives the requested additional
information.
(2) The interest is payable with the payment of the claim. An
insurer is not required to pay interest that is in the amount of
$2 or less on any claim.
(3) The availability of interest under subsection (1) of this
section is in addition to and not in lieu of administrative
actions and penalties that may be imposed by the Director of the
Department of Consumer and Business Services under the Insurance
Code. + }
SECTION 4. { + The Director of the Department of Consumer and
Business Services shall report to the Seventy-third Legislative
Assembly on the implementation of and compliance with sections 2
and 3 of this 2001 Act. + }
SECTION 5. ORS 743.801 is amended to read:
743.801. As used in ORS 743.699, 743.801, 743.803, 743.804,
743.806, 743.807, 743.808, 743.809, 743.811, 743.814, 743.817,
743.819, 743.821, 743.823, 743.827, 743.829, 743.831, 743.834,
743.837 and 743.839 { + and sections 2 and 3 of this 2001
Act + }:
(1) 'Emergency medical condition' means a medical condition
that manifests itself by symptoms of sufficient severity that a
prudent layperson possessing an average knowledge of health and
medicine would reasonably expect that failure to receive
immediate medical attention would place the health of a person,
or a fetus in the case of a pregnant woman, in serious jeopardy.
(2) 'Emergency medical screening exam' means the medical
history, examination, ancillary tests and medical determinations
required to ascertain the nature and extent of an emergency
medical condition.
(3) 'Emergency services' means those health care items and
services furnished in an emergency department and all ancillary
services routinely available to an emergency department to the
extent they are required for the stabilization of a patient.
{ + (4) 'Enrollee' has the meaning given that term in ORS
743.730. + }
{ - (4) - } { + (5) + } 'Grievance' means a written
complaint submitted by or on behalf of an enrollee regarding the:
(a) Availability, delivery or quality of health care services,
including a complaint regarding an adverse determination made
pursuant to utilization review;
(b) Claims payment, handling or reimbursement for health care
services; or
(c) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
{ - (5) - } { + (6) + } 'Health benefit plan' has the
meaning provided for that term in ORS 743.730.
{ - (6) - } { + (7) + } 'Independent practice association'
means a corporation wholly owned by providers, or whose
membership consists entirely of providers, formed for the sole
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purpose of contracting with insurers for the provision of health
care services to enrollees, or with employers for the provision
of health care services to employees, or with a group, as
described in ORS 743.522, to provide health care services to
group members.
{ - (7) - } { + (8) + } 'Insurer' has the meaning provided
for that term in ORS 731.106. For purposes of ORS 743.699,
743.801, 743.803, 743.804, 743.806, 743.807, 743.808, 743.809,
743.811, 743.814, 743.817, 743.819, 743.821, 743.823, 743.827,
743.829, 743.831, 743.834, 743.837, 743.839, 750.055 and
750.333 { + and sections 2 and 3 of this 2001 Act + }, 'insurer'
also includes a health care service contractor as defined in ORS
750.005.
{ - (8) - } { + (9) + } 'Managed health insurance' means
any health benefit plan that:
(a) Requires an enrollee to use, or creates incentives for an
enrollee to use, providers managed, owned, under contract with or
employed by the insurer; and
(b) Reimburses any of the providers described in paragraph (a)
of this subsection on a basis other than fee-for-service billing
or discounts from fee-for-service billing.
{ - (9) - } { + (10) + } 'Medical services contract' means
a contract between an insurer and an independent practice
association, between an insurer and a provider, between an
independent practice association and a provider or organization
of providers, between medical or mental health clinics, and
between a medical or mental health clinic and a provider to
provide medical or mental health services. 'Medical services
contract' does not include a contract of employment or a contract
creating legal entities and ownership thereof that are authorized
under ORS chapter 58, 60 or 70, or other similar professional
organizations permitted by statute.
{ - (10) - } { + (11) + } 'Prior authorization' means a
determination by an insurer prior to provision of services that
the insurer will provide reimbursement for the services. 'Prior
authorization ' does not include referral approval for evaluation
and management services between providers.
{ - (11) - } { + (12) + } 'Provider' means a person
licensed, certified or otherwise authorized or permitted by laws
of this state to administer medical or mental health services in
the ordinary course of business or practice of a profession.
{ - (12) - } { + (13) + } 'Stabilization' means that,
within reasonable medical probability, no material deterioration
of an emergency medical condition is likely to occur.
{ - (13) - } { + (14) + } 'Utilization review' means a set
of formal techniques used by an insurer or delegated by the
insurer designed to monitor the use of or evaluate the medical
necessity, appropriateness, efficacy or efficiency of health care
services, procedures or settings.
SECTION 6. ORS 750.055 is amended to read:
750.055. (1) The following provisions of the Insurance Code
shall apply to health care service contractors to the extent so
applicable and not inconsistent with the express provisions of
ORS 750.005 to 750.095:
(a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.362,
731.382, 731.385, 731.386, 731.390, 731.398 to 731.430, 731.450,
731.454, 731.488, 731.504, 731.508, 731.509, 731.510, 731.511,
731.512, 731.574 to 731.620, 731.592, 731.594, 731.640 to
731.652, 731.730, 731.731, 731.735, 731.737, 731.740, 731.750,
731.804 and 731.844 to 731.992.
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(b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.549 and
732.574 to 732.592.
(c)(A) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.620, 733.635 to 733.680 and 733.695 to
733.780 apply to not-for-profit health care service contractors.
(B) ORS chapter 733, not including ORS 733.630, applies to
for-profit health care service contractors.
(d) ORS chapter 734.
(e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.412, 743.472, 743.492, 743.495, 743.498, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.555,
743.556, 743.560, 743.600 to 743.610, 743.650 to 743.656,
743.693, 743.697, 743.699, 743.701, 743.704, 743.706 to 743.712,
743.721, 743.722, 743.726, 743.727, 743.728, 743.729, 743.804,
743.807, 743.808, 743.809, 743.814 to 743.839, 743.842, 743.845
and 743.847 { + and sections 2 and 3 of this 2001 Act + }.
(f) The provisions of ORS chapter 744 relating to the
regulation of agents.
(g) ORS 746.005 to 746.140, 746.160, 746.180, 746.220 to
746.370 and 746.600 to 746.690.
(h) ORS 743.714, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
(i) ORS 735.600 to 735.650.
(j) ORS 743.680 to 743.689.
(k) ORS 744.700 to 744.740.
(L) ORS 743.730 to 743.773.
(m) ORS 731.485, except in the case of a group practice health
maintenance organization that is federally qualified pursuant to
Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
(2) For the purposes of this section only, health care service
contractors shall be deemed insurers.
(3) Any for-profit health care service contractor organized
under the laws of any other state which is not governed by the
insurance laws of such state, will be subject to all requirements
of ORS chapter 732.
(4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
SECTION 7. Sections 2 and 3 of this 2001 Act and the amendments
to ORS 743.801 and 750.055 by sections 5 and 6 of this 2001 Act
apply to health benefit plans issued or renewed on or after the
operative date of sections 2 and 3 of this 2001 Act and the
amendments to ORS 743.801 and 750.055 by sections 5 and 6 of this
2001 Act.
SECTION 8. { + Except as provided in section 9 of this 2001
Act, sections 2 and 3 of this 2001 Act and the amendments to ORS
743.801 and 750.055 by sections 5 and 6 of this 2001 Act become
operative on January 1, 2002. + }
SECTION 9. { + The Director of the Department of Consumer and
Business Services may take any action before the operative date
of sections 2 and 3 of this 2001 Act and the amendments to ORS
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743.801 and 750.055 by sections 5 and 6 of this 2001 Act that is
necessary to enable the director to exercise, on and after the
operative date of sections 2 and 3 of this 2001 Act and the
amendments to ORS 743.801 and 750.055 by sections 5 and 6 of this
2001 Act, all the duties, functions and powers conferred on the
director by sections 2 and 3 of this 2001 Act and the amendments
to ORS 743.801 and 750.055 by sections 5 and 6 of this 2001
Act. + }
SECTION 10. { + This 2001 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2001 Act takes effect on
its passage. + }
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Passed by Senate May 15, 2001
...........................................................
Secretary of Senate
...........................................................
President of Senate
Passed by House June 1, 2001
...........................................................
Speaker of House
Enrolled Senate Bill 894 (SB 894-A) Page 5
Received by Governor:
......M.,............., 2001
Approved:
......M.,............., 2001
...........................................................
Governor
Filed in Office of Secretary of State:
......M.,............., 2001
...........................................................
Secretary of State
Enrolled Senate Bill 894 (SB 894-A) Page 6