INSURANCE PROVIDER RIGHTS

...but first, give your clients a voice:

According to Oregon Law, insurance providers must contract with a sufficient number of accessible providers so that clients receive treatment without unreasonable delay ( ORS 743B.505). COPACT offers a webpage for clients that outlines consumer rights when it comes to insurance practices and provides links to the complaint processes if those rights have been violated, along with sample forms and verbiage. Please consider adding the link below to your website and/or refer clients to this link whenver you hear a complaint.
Let's give our clients a voice!

LINK TO SHARE         www.copactoregon.com/consumers

Your rights as an insurance provider:

  • ​​An insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim (ORS 743B.450(1))
    • ​If an insurer requires additional information before payment of a claim, the insurer shall notify the provider in writing with an explanation of the additional information needed, then pay or deny the claim not later than 30 days after the date they receive the additional information
    • If an insurer needs more time to determine whether the claim should be accepted or denied, it shall notify the provider in writing within 30 days and provide an explanation as to why more time is needed. Forty-five days from the date of such initial notification and every 45 days thereafter, the insurer shall notify the provider in writing of the reason additional time is needed (OAR 836-080-0235(4)
  • An insurer that fails to pay a claim to a provider within the 30 day timeline shall pay simple interest of 12 percent per annum on the unpaid amount of the claim that is due and owing (unless that amount is under $2.00) (ORS 743B.452(1))
  • Requests for prior authorization of nonemergency services must be answered within two business days (ORS 743B.423(2)(d))
  • Insurers must provide fair claim settlement practices including: promptly providing an explanation for the denial of a claim, promptly replying to all communication related to claims, conducting a reasonable investigation before denying a claim, not delaying investigations or payment of claims, and not misrepresenting facts or policy provisions in regard to claims (ORS 746.230(1)(m))
  • ​No statements may be made, in any form, which are untrue, deceptive or misleading (ORS 746.110)
  • Insurers must provide information about the criteria it uses to decide if a service or treatment is medically necessary (MHPAEA)
  • ​In network mental health providers must be paid a reimbursement rate that is equivalent to the reimbursement rate for in-network medical providers (ORS 753B.462(2)(a))
  • Utilization management procedures for mental health providers cannot be more restrictive than the utilization management procedures for medical providers (this includes longer office visits which cannot be more restrictive for mental health providers versus medical providers) (ORS 753B.462(2)(b))
  • Statutes regarding "clawbacks" can be found here: ORS 743B.451
  • A health insurer shall approve or reject a completed application for credentialing (paneling) within 90 days of receiving the application (ORS 743B.454(2))  
    • A health insurer shall pay all claims for services covered by the health insurer during the credentialing period (ORS 743B.454(3)(a))  ​

If you suspect your rights have been violated:

COMMERCIAL (PRIVATE) INSURANCE:

Commercial insurance companies are regulated by the Department of Consumer and Business Services and are routinely fined up to $10,000 per violation. Many counselors and therapists (not to mention clients) do not fully understand their rights which means violations often go unnoticed. Insurers cannot be held accountable unless the proper regulating agency knows that they are violating the rules.

If a private insurance company has violated any of the above rules, it is imperative that the DCBS be informed. The online complaint process is quick and easy:

Click here to access the online complaint form
  • It is only necessary to complete the required field, marked with a red "*".
  • Though a response to your complaint may be slow, it is very important that the DCBS be informed of any violations as this is the only means to hold insurance providers accountable. ​
Click here to print the PDF complaint form
  • Though a response to your complaint may be slow, it is very important that the DCBS be informed of any violations as this is the only means to hold insurance providers accountable. ​
If you have any questions about your rights in regard to private insurance practices, you can email DCBS directly at: [email protected]  or call:  888-877-4894
You can view the private insurance companies that have been investigated/fined and read the full reports going back several years with this handy search tool:

NOTICES AND ORDERS SEARCH  
Simply choose the year and select, "insurance" for a list of all reports,
or you can enter a specific insurance provider name.

STATE INSURANCE (OHP, OPEN CARD, OR INDIVIDUAL CCOs):

Providers acting on behalf of Oregon Health Plan (OHP) members can contact the Oregon Health Authority Ombuds Program around access to care and quality of care concerns for OHP members. The Ombuds Program has a team of Ombudspersons who advocate for OHP members. 

Contact information:
Send a secure email from the Ombuds Website
Phone: 877-642-0450 or 503-947-2346 (secure, message line only)
(نتكلم العربية  Hablamos Español)

Click here to read the OHA Administrative Rules for behavioral health)