Rules affected: OAR 836-053-1200, 836-053-1203
Need for Rules:
2019 Senate Bill 249, enrolled at 2019 Oregon Laws Chapter 284, establishes new requirements for health insurance prior authorization processes.
Prior authorization requirements are included in many health insurance plans. If a covered benefit requires prior authorization, the health insurer may review a patient’s condition and medical history, as well as any evidence of medical necessity supplied by the medical provider or patient, before approving or denying coverage. Oregon law prohibits health benefit plans from imposing prior authorization requirements on some services, such as emergency services (ORS 743A.012), but many non-emergency services may be subject to such requirements.
Section 2 of the law imposes new trade practice requirements on health insurer prior authorization practices. These requirements are similar to those applied to claims for reimbursement in Oregon’s unfair claims settlement practices statute, ORS 746.230, and include a requirement to act promptly, equitably and in good faith to approve requests for prior authorization for medically necessary covered services. This section expressly grants DCBS the authority to write rules to implement its provisions. These requirements apply to all policies and certificates of health insurance, as defined by ORS 731.162.
The law amends existing requirements for prior authorization codified in ORS 743B.422 and ORS 743B.423; these statutes apply only to health benefit plans as defined by ORS 743B.005. Specifically, the law requires that a determination be made in response to a prior authorization request within a reasonable period of time appropriate to the medical circumstances, but no later than two business days following receipt of a request by health insurance carrier, unless additional information is required to make a determination. If additional information is required, the carrier must issue a notice in writing to both the enrollee and the requesting health care provider (if any) specifying all of the information necessary to make a determination. If the carrier receives a response, a determination must be made no later than two business days following receipt of the response; regardless of whether a response is received, the carrier must issue a determination no later than 15 total days following the request for additional information. The amendments to ORS 743B.422 and ORS 743B.423 also clarify that these requirements apply to prior authorization requests made by enrollees, not just by health care providers.
The law revises ORS 743B.001 to make technical amendments to the existing definitions of “prior authorization” and “utilization review,” as well as to add the denial of a prior authorization request to the list of actions falling under the definition of “adverse benefit determination.” The law also makes a variety of non-substantive changes to other statutes.
Two rules are proposed to implement this new law:
- Revisions to OAR 836-053-1200 to align its requirements with the new requirements for health benefit plans imposed by the revisions to ORS 743B.422 and ORS 743B.423.
- A new rule (proposed OAR 836-053-1203) that applies to all policies and certificates of health insurance other than health benefit plans to establish standards for when an insurer acts promptly in response to a request for prior authorization within the meaning of 2019 Oregon Laws Ch. 284 Section 2(2)(e).
The proposed rules are necessary to correct inconsistencies between existing administrative rules and the new law and to establish uniform standards for compliance regarding timelines and communication related to prior authorization that will help ensure fairness and consistent treatment for consumers, health care providers, and issuers of all lines of health insurance.
Filed: October 29, 2019
Public hearing: November 22, 2019, 1:30p
Last day for public comment: November 29, 2019, 5 p.m.