Or. Admin. Code § 836-053-1310

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1310 - Contracting Requirements

(1) To be considered for contracting with the Director of the Department of Consumer and Business Services as an independent review organization under ORS 743B.253 for the purpose of providing independent review under 743B.252, an independent review organization must submit to the director a response to the director's request for proposal according to its requirements. The response must include:

(a) For an independent review organization that is publicly held, the name of each stockholder or owner of more than five percent of any stock or options;

(b) The name of any holder of bonds or notes of the independent review organization that exceed $100,000;

(c) The name and type of business of each corporation or other organization that the independent review organization controls or is affiliated with and the nature and extent of the affiliation or control;

(d) The name and a biographical sketch of each director, officer and executive of the independent review organization and any entity listed under subsection (c) of this section and a description of any relationship the named individual has with:

(A) An insurer;

(B) A utilization review agent;

(C) A nonprofit or for-profit hospital or other health care corporation;

(D) A doctor of medicine or osteopathy, a provider or other health care professional;

(E) A drug or device manufacturer; or

(F) A group representing any of the entities described by paragraph (A) to (E) of this subsection;

(e) The percentage of the independent review organization's revenues that the independent review organization anticipates will be derived from reviews conducted under ORS 743B.256;

(f) A description of the areas of expertise of the medical reviewers making review determinations for the independent review organization, as well as policies and standards of the independent review organization that address qualifications, training and assignment of all types of medical reviewers and that are compliant with requirements of OAR 836-053-1317;

(g) The procedures that the independent review organization will use in making review determinations regarding reviews conducted under ORS 743B.256;

(h) Attestations that all requirements will be met;

(i) Evidence of accreditation by a nationally recognized private accrediting organization;

(j) Other documentation, including but not limited to legal and financial information, policies and procedures, and data that are pertinent to requirements of ORS 743B.256 and OAR 836-053-1315; and

(k) Any other requirements established by the director that demonstrate the independent review organization's ability to meet all requirements for contracting as an independent review organization in this state.

(2) In order to enable the director to consider the response of an independent review organization under section (1) of this rule:

(a) The independent review organization must authorize release of information from primary sources, including full reports of site visits, inspections and audits; and

(b) The Director may require the independent review organization to indicate which documents demonstrate compliance with specific statutory requirements under ORS 743B.256 and OAR 836-053-1315.

(3) Investigation and verification activities of the director regarding the independent review organization may include, but are not limited to:

(a) Review of the response of the independent review organization to the request for proposals and its filings for completeness and compliance with standards;

(b) On-site survey or examination;

(c) Primary-source verification with accreditation or regulatory bodies of compliance with requirements that are used to demonstrate compliance with applicable standards established in ORS 743B.256 and OAR 836-053-1315; and

(d) Other means of determining regulatory and accreditation histories.

Or. Admin. Code § 836-053-1310

ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 15-2018, minor correction filed 08/20/2018, effective 8/20/2018

Statutory/Other Authority: 743B.252, 743B.253 & ORS 731.244

Statutes/Other Implemented: ORS 743B.253