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The Oregon Administrative Rules contain OARs filed through July 15, 2014
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION

 

DIVISION 100

HEALTH INSURANCE REFORM

Children’s Health Insurance Childrens Reinsurance Program

836-100-0010 [Renumbered to 836-100-0020]

Administrative Streamlining and Simplification

836-100-0100

Authority; Purpose; Scope

(1) OAR 836-100-0100 to 836-100-0120 are adopted by the Director of the Department of Consumer and Business Services pursuant to ORS 743.061. The purpose of OAR 836-100-0100 to 836-100-0120 is to establish the uniform administrative standards that health insurers and health care entities are required to comply with under ORS 743.061. The uniform standards have been developed by the Office for Oregon Health Policy and Research in consultation with stakeholders pursuant to ORS 743.062.

(2) The uniform standards adopted under OAR 836-100-0100 to 836-100-0120 apply to all health insurers and health care entities in Oregon as specified in each companion guide.

Stat. Auth.: ORS 731.244 & 743.061
Stats. Implemented: ORS 743.061
Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0105

Definitions

(1) “Electronic transaction” means to conduct a transaction:

(a) Through the use of a computer program or an electronic or other automated means independently to initiate an action or respond to electronic records or performances in whole or in part, without review or action by an individual; or

(b) Through the use of a web portal or the internet.

(2)(a) “Health care entity” includes:

(A) A health care service contractor as required under ORS 750.055;

(B) A multiple employer welfare arrangement as required under ORS 750.333;

(C) A prepaid managed care health services organization as defined in ORS 414.736;

(D) Any entity licensed as a third party administrator under ORS 744.702;

(E) Any person or public body that either individually or jointly established a self-insurance plan, program or contract, including but not limited to persons and public bodies that are otherwise exempt from the Insurance Code under ORS 731.036;

(F) A health care clearinghouse or other entity that processes or facilitates the processing of health care financial and administrative transactions from a nonstandard format to a standard format; and

(G) Any other person identified by the department that processes health care financial and administrative transactions between a health care provider and an entity described in this subsection.

(b) “Health care entity” does not include a pharmacy or a pharmacy benefits manager.

(3) “Health insurer” means any insurer authorized to transact health insurance in Oregon.

(4) “Oregon Companion Guide” means one of the compilations of uniform standards adopted by the Department of Consumer and Business Services and posted on the Oregon Insurance Division’s website that provide standards for health care financial and administrative transactions. The following Oregon Companion Guides are applicable to respective transactions with health insurers and health care entities in Oregon:

(a) Oregon Companion Guide for the Implementation of the ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271).

(b) Oregon Companion Guide for the Implementation of the ASC X12/005010X212: Claim Status Request and Response (276/277).

(c) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12N/005010X221 Health Care Claim Payment/Advice (835).

(d) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X222 Health Care Claim: Professional (837).

(e) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X223 Health Care Claim: Institutional (837).

(f) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X224 Health Care Claim: Dental (837).

(5) “Oregon Companion Guide Oversight Committee” means the committee appointed jointly by the Department of Consumer and Business Services and the Oregon Health Authority to carry out the responsibilities under OAR 836-100-0120.

(6) “Provider” means a health care provider that provides health care or medical services within Oregon for a fee and is eligible for reimbursement for these services.

Stat. Auth.: ORS 731.244 & 743.061
Stats. Implemented: ORS 743.061
Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0110

Adoption of Standards

(1) On or after October 1, 2012, to the extent possible, all health insurers and health care entities must conduct eligibility benefit inquiry and response transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Eligibility Benefit Inquiry and Response in accordance with the following schedule:

(2) On and after October 1, 2012, to the extent possible, all health insurers and health care entities must conduct claims or encounter transactions with health care providers in conformance with the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Claim: Professional, Oregon Companion Guide for Health Care Claim: Institutional and Oregon Companion Guide for Health Care Claim: Dental in accordance with the following schedule:

(3) On and after January 1, 2014, to the extent possible, all health insurers and health care entities must conduct claims payment or advice transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Claim Payment or Advice.

(4) On and after January 1, 2014, to the extent possible, all health insurers and health care entities must conduct claims status request and response transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Claim Status Request and Response.

Stat. Auth.: ORS 731.244 & 743.061
Stats. Implemented: ORS 743.061
Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0115

Waiver

If the director has granted a waiver before January 1, 2014, upon expiration of the waiver, the health insurer or health care entity shall comply with the requirements of OAR 836-100-0100.

Stat. Auth.: ORS 731.244 & 743.061
Stats. Implemented: ORS 743.061
Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0120

Review and Update of Standards

(1) The Department of Consumer and Business Services and the Oregon Health Authority shall jointly appoint an Oregon Companion Guide Oversight Committee. The members appointed to the committee must demonstrate knowledge of the transactions subject to the Oregon Companion Guides, financial knowledge, operational industry or business expertise, or knowledge of the technology necessary to implement the requirements of the companion guides.

(2) The Oregon Companion Guide Oversight Committee shall meet as needed to review the implementation of the administrative standards encompassed by the Oregon Companion Guides. The committee shall address issues identified by the Department of Consumer and Business Services and the Oregon Health Authority, including but not limited to:

(a) Consider and make recommendations to Oregon Health Authority and Department of Consumer and Business Services about needed changes to the guides in order to keep the guide up to date with industry and federal government driven changes.

(b) Provide reports to Department of Consumer and Business Services and Oregon Health Authority regarding health insurer and provider participation, successes and areas for improvement.

(c) Review any proposed changes developed by Oregon Health Authority to the standards or companion guides.

(d) Review any proposed changes developed by Department of Consumer and Business Services to the rules requiring compliance with the companion guides.

Stat. Auth.: ORS 731.244 & 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats. Implemented: 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.: ID 12-2011, f. & cert. ef. 7-15-11

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