Oregon Revised Statutes Chapter 656 § 656.260 — Certification procedure for managed health care provider; required findings;

Certification procedure for managed health care provider; required findings; denial or termination of provider authorization; scope of director’s review; confidentiality of certain information; immunity from liability; rules; medical service dispute resolution; penalties. (1) Any health care provider or group of medical service providers may make written application to the Director of the Department of Consumer and Business Services to become certified to provide managed care to injured workers for injuries and diseases compensable under this chapter. However, nothing in this section authorizes an organization that is formed, owned or operated by an insurer or employer other than a health care provider to become certified to provide managed care. (2) Each application for certification shall be accompanied by a reasonable fee prescribed by the director. A certificate is valid for such period as the director may prescribe unless sooner revoked or suspended. (3) Application for certification shall be made in such form and manner and shall set forth such information regarding the proposed plan for providing services as the director may prescribe. The information shall include, but not be limited to: (a) A list of the names of all individuals who will provide services under the managed care plan, together with appropriate evidence of compliance with any licensing or certification requirements for that individual to practice in this state. (b) A description of the times, places and manner of providing services under the plan. (c) A description of the times, places and manner of providing other related optional services the applicants wish to provide. (d) Satisfactory evidence of ability to comply with any financial requirements to ensure delivery of service in accordance with the plan which the director may prescribe. (4) The director shall certify a health care provider or group of medical service providers to provide managed care under a plan if the director finds that the plan: (a) Proposes to provide medical and health care services required by this chapter in a manner that: (A) Meets quality, continuity and other treatment standards adopted by the health care provider or group of medical service providers in accordance with processes approved by the director; and (B) Is timely, effective and convenient for the worker. (b) Subject to any other provision of law, does not discriminate against or exclude from participation in the plan any category of medical service providers and includes an adequate number of each category of medical service providers to give workers adequate flexibility to choose medical service providers from among those individuals who provide services under the plan. However, nothing in the requirements of this paragraph shall affect the provisions of ORS 441.055 relating to the granting of medical staff privileges. (c) Provides appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service. (d) Provides adequate methods of peer review, service utilization review, quality assurance, contract review and dispute resolution to ensure appropriate treatment or to prevent inappropriate or excessive treatment, to exclude from participation in the plan those individuals who violate these treatment standards and to provide for the resolution of such medical disputes as the director considers appropriate. A majority of the members of each peer review, quality assurance, service utilization and contract review committee shall be physicians licensed to practice medicine by the Oregon Medical Board. As used in this paragraph: (A) “Contract review” means the methods and processes whereby the managed care organization monitors and enforces its contracts with participating providers for matters other than matters enumerated in subparagraphs (C), (D) and (E) of this paragraph. (B) “Dispute resolution” includes the resolution of disputes arising under peer review, service utilization review and quality assurance activities between insurers, self-insured employers, workers and medical and health care service providers, as required under the certified plan. (C) “Peer review” means evaluation or review of the performance of colleagues by a panel with similar types and degrees of expertise. Peer review requires participation of at least three physicians prior to final determination. (D) “Quality assurance” means activities to safeguard or improve the quality of medical care by assessing the quality of care or service and taking action to improve it. (E) “Service utilization review” means evaluation and determination of the reasonableness, necessity and appropriateness of a worker’s use of medical care resources and the provision of any needed assistance to clinician or member, or both, to ensure appropriate use of resources. “Service utilization review” includes prior authorization, concurrent