75th OREGON LEGISLATIVE ASSEMBLY--2009 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 1483
 
                         Senate Bill 506
 
Sponsored by Senators MONNES ANDERSON, KRUSE, Representatives
  SCHAUFLER, THOMPSON (at the request of Oregon Medical
  Association)
 
 
                             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 insurer to allow web-based or telephone access by
provider to specified information regarding claim for
reimbursement. Prohibits insurer from denying claim if provider
obtains information within 72 hours prior to service or
treatment.  Makes violation subject to civil penalty, not to
exceed $1,000.  Authorizes provider or enrollee to bring civil
action for violation of Act and to recover costs, disbursements
and attorney fees.
 
                        A BILL FOR AN ACT
Relating to health insurance; amending ORS 743.837.
Be It Enacted by the People of the State of Oregon:
  SECTION 1. ORS 743.837 is amended to read:
  743.837.   { - Except in the case of misrepresentation, prior
authorization determinations shall be subject to the following
requirements: - }
    { - (1) Prior authorization determinations relating to
benefit coverage and medical necessity shall be binding on the
insurer if obtained no more than 30 days prior to the date the
service is provided. - }
    { - (2) Prior authorization determinations relating to
enrollee eligibility shall be binding on the insurer if obtained
no more than five business days prior to the date the service is
provided. - }
   { +  (1) The interactive website and toll-free telephone
described in ORS 743.874 (5) and 743.876 (5) shall allow
providers to obtain prior authorization and to determine:
  (a) If a patient is enrolled in a health benefit plan;
  (b) If a service or treatment is covered by the enrollee's
plan;
  (c) The insurer's allowable charge for the service or
treatment;
  (d) Whether the enrollee's deductible has been met; and
  (e) The amount of the enrollee's copayment or coinsurance for
the service or treatment.
  (2) An insurer may not deny a claim from a provider for
reimbursement under a health benefit plan for a service or
treatment if the provider has obtained the information described
 
in subsection (1) of this section within 72 hours prior to the
provision of the service or treatment.
  (3) In addition to and not in lieu of any administrative
actions or penalties that may be imposed by the Director of the
Department of Consumer and Business Services under the Insurance
Code, the director may impose a civil penalty of not more than
$1,000 for each violation of this section.
  (4)(a) A provider or an enrollee who is harmed by a violation
of this section may bring a civil action against an insurer for
damages or any other remedy available at law or in equity.
  (b) A prevailing plaintiff may recover reasonable costs,
disbursements and attorney fees in an action brought under this
subsection. + }
                         ----------