75th OREGON LEGISLATIVE ASSEMBLY--2009 Regular Session
Enrolled
Senate Bill 507
Sponsored by Senators MONNES ANDERSON, KRUSE, Representatives
SCHAUFLER, THOMPSON; Senator MORRISETTE (at the request of
Oregon Medical Association)
CHAPTER ................
AN ACT
Relating to preferred providers; creating new provisions;
amending ORS 743.801; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2009 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) As used in this section:
(a) 'Complete application' means a provider's application to a
health insurer to become a credentialed provider that includes:
(A) Information required by the health insurer;
(B) Proof that the provider is licensed by a health
professional regulatory board as defined in ORS 676.160;
(C) Proof of current registration with the Drug Enforcement
Administration of the United States Department of Justice, if
applicable to the provider's practice; and
(D) Proof that the provider is covered by a professional
liability insurance policy or certification meeting the health
insurer's requirements.
(b) 'Credentialing period' means the period beginning on the
date a health insurer receives a complete application and ending
on the date the health insurer approves or rejects the complete
application or 90 days after the health insurer receives the
complete application, whichever is earlier.
(c) 'Health insurer' means an insurer that offers managed
health insurance or preferred provider organization insurance,
other than a health maintenance organization as defined in ORS
750.005.
(2) A health insurer shall approve or reject a complete
application within 90 days of receiving the application.
(3)(a) A health insurer shall pay all claims for medical
services covered by the health insurer that are provided by a
provider during the credentialing period.
(b) A provider may submit claims for medical services provided
during the credentialing period during or after the credentialing
period.
(c) A health insurer may pay claims for medical services
provided during the credentialing period:
(A) During or after the credentialing period.
(B) At the rate paid to nonparticipating providers.
(d) If a provider submits a claim for medical services provided
during the credentialing period within six months after the end
Enrolled Senate Bill 507 (SB 507-A) Page 1
of the credentialing period, the health insurer may not deny
payment of the claim on the basis of the health insurer's rules
relating to timely claims submission.
(4) Subsection (3) of this section does not require a health
insurer to pay claims for medical services provided during the
credentialing period if:
(a) The provider was previously rejected or terminated as a
participating provider in any health benefit plan underwritten or
administered by the health insurer;
(b) The rejection or termination was due to the objectively
verifiable failure of the provider to provide medical services
within the recognized standards of the provider's profession; and
(c) The provider was given the opportunity to contest the
rejection or termination before a panel of peers in a proceeding
conducted in conformity with the Health Care Quality Improvement
Act of 1986, 42 U.S.C. 11101 et seq. + }
SECTION 3. ORS 743.801 is amended to read:
743.801. As used in ORS 743.801, 743.803, 743.804, 743.806,
743.807, 743.808, 743.811, 743.814, 743.817, 743.819, 743.821,
743.823, 743.827, 743.829, 743.831, 743.834, 743.837, 743.839,
743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862,
743.863, 743.864, 743.911, 743.913 and 743A.012 { + and section
2 of this 2009 Act + }:
(1) 'Emergency medical condition' means a medical condition
that manifests itself by acute symptoms of sufficient severity,
including severe pain, 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.
(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.
(6) 'Health benefit plan' has the meaning provided for that
term in ORS 743.730.
(7) 'Independent practice association' means a corporation
wholly owned by providers, or whose membership consists entirely
of providers, formed for the sole 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.
(8) 'Insurer' has the meaning provided for that term in ORS
731.106. For purposes of ORS 743.801, 743.803, 743.804, 743.806,
743.807, 743.808, 743.811, 743.814, 743.817, 743.819, 743.821,
Enrolled Senate Bill 507 (SB 507-A) Page 2
743.823, 743.827, 743.829, 743.831, 743.834, 743.837, 743.839,
743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862,
743.863, 743.864, 743.911, 743.913, 743A.012, 750.055 and
750.333, ' insurer' also includes a health care service
contractor as defined in ORS 750.005.
(9) 'Managed health insurance' means any health benefit plan
that:
(a) Requires an enrollee to use a specified network or networks
of providers managed, owned, under contract with or employed by
the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
(b) In addition to the requirements of paragraph (a) of this
subsection, offers a point-of-service provision that allows an
enrollee to use providers outside of the specified network or
networks at the option of the enrollee and receive a reduced
level of benefits.
(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.
(11)(a) 'Preferred provider organization insurance' means any
health benefit plan that:
(A) Specifies a preferred network of providers managed, owned
or under contract with or employed by an insurer;
(B) Does not require an enrollee to use the preferred network
of providers in order to receive benefits under the plan; and
(C) Creates financial incentives for an enrollee to use the
preferred network of providers by providing an increased level of
benefits.
(b) 'Preferred provider organization insurance' does not mean a
health benefit plan that has as its sole financial incentive a
hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable
amounts that are specified in the medical services contracts.
(12) '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.
(13) '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.
(14) 'Stabilization' means that, within reasonable medical
probability, no material deterioration of an emergency medical
condition is likely to occur.
(15) '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 4. { + Section 2 of this 2009 Act applies to requests
to enter into medical services contracts submitted by a provider
on or after the effective date of this 2009 Act. + }
Enrolled Senate Bill 507 (SB 507-A) Page 3
SECTION 5. { + This 2009 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2009 Act takes effect on its
passage. + }
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Passed by Senate June 2, 2009
...........................................................
Secretary of Senate
...........................................................
President of Senate
Passed by House June 25, 2009
...........................................................
Speaker of House
Enrolled Senate Bill 507 (SB 507-A) Page 4
Received by Governor:
......M.,............., 2009
Approved:
......M.,............., 2009
...........................................................
Governor
Filed in Office of Secretary of State:
......M.,............., 2009
...........................................................
Secretary of State
Enrolled Senate Bill 507 (SB 507-A) Page 5