746.233 Unfair claim settlement practices with respect to prior authorizations of health care items or services
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746.233 Unfair claim settlement practices with respect to prior authorizations of health care items or services.
(1)As used in this section, “prior authorization” has the meaning given that term in ORS 743B.001.
(2)An insurer offering a policy or certificate of health insurance may not, in making a determination on a health care provider or enrollee’s request for prior authorization of a health care item or service, perform any of the following unfair claim settlement practices:
(a)Misrepresent facts of policy provisions;
(b)Fail to acknowledge and act upon communications relating to the request;
(c)Fail to adopt and implement reasonable standards for the prompt investigations of prior authorization requests;
(d)Make a determination without conducting a reasonable investigation based on all available information;
(e)Fail to act promptly, equitably and in good faith to approve the request for prior authorization that is medically necessary and covered under the terms of the policy;
(f)Require a provider or enrollee to submit substantially identical information more than one time in the course of making the determination; or
(g)If the request for prior authorization is denied, fail to promptly provide a complete and thorough explanation of the terms of the policy or certificate that the insurer relied upon and the factual or legal basis for the denial.
(3)An insurer may not engage in a pattern or practice of refusing, without just cause, to approve requests for prior authorization of items or services covered under its policies and certificates as demonstrated by:
(a)A substantial increase in the number of consumer complaints against the insurer received by the Department of Consumer and Business Services regarding denials of prior authorization;
(b)A substantial number of lawsuits filed by:
(A)A provider against the insurer or an insured based on the failure to approve a request for prior authorization for an item or service furnished by the provider; or
(B)A provider or enrollee against the insurer based on the failure to approve a prior authorization request for an item or service; or
(c)Other evidence that the department deems relevant.
(4)The department may adopt rules necessary to carry out the provisions of this section. [2019 c.284 §2]
Note: 746.233 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 746 or any series therein. See Preface to Oregon Revised Statutes for further explanation.