Or. Admin. Code § 836-053-1317

Current through Register Vol. 63, No. 10, October 1, 2024

Section 836-053-1317 - Professional Qualifications

(1) A doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the laws of another state that govern the licensing of doctors of medicine or osteopathy shall be responsible for each final independent review determination made by an independent review organization, and in making a determination shall consult with other medical reviewers as appropriate.

(2) An independent review organization shall have a medical director who holds a current unrestricted license as a medical doctor or osteopathic physician and has had experience in direct patient care. The medical director shall provide guidance for clinical aspects of the independent review process and oversee the independent review organization's quality assurance and credentialing programs.

(3) An independent review organization shall maintain policies and practices that assure that each medical reviewer:

(a) Holds a current, unrestricted license, certification or registration in this state, or current, unrestricted credentials from another state;

(b) Has at least five years of recent clinical experience;

(c) Is certified by an appropriate member board of the American Board of Medical Specialties if board certification is available for the specialty or profession in which the medical reviewer is engaged; and

(d) Has the ability to apply scientific standards of evidence in judging research literature pertinent to review issues, as demonstrated through relevant training or professional experience.

(4) A medical reviewer who is assigned to a case must have at least five years of recent clinical experience dealing with the same health conditions under review or similar conditions. Exceptions may be made to this requirement in unusual situations when the only experts available for a highly specialized review are in academic or research work and do not meet the clinical experience requirement.

(5) An independent review organization must maintain a training program for staff and medical reviewers, addressing at least:

(a) Confidentiality;

(b) Neutrality and conflict of interest;

(c) Appropriate conduct of reviews; and

(d) Documentation of evidence for determination.

Or. Admin. Code § 836-053-1317

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 17-2018, minor correction filed 08/20/2018, effective 8/20/2018

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

Statutes/Other Implemented: ORS 743B.253