OAR 836-053-0028: Primary Care Provider Assignment Methodology

(1) As used in these rules: (a) “Enrollee” means an employee, dependent of the employee or an individual otherwise eligible for a group or individual health benefit plan who has enrolled for coverage under the terms of the plan. (b) “Primary care provider” means an individual licensed or certified in this state to provide outpatient, non-specialty medical services or the coordination of health care for the purpose of: (A) Promoting or maintaining mental and physical health and wellness; and (B) Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness. (2) An insurer offering an individual or group policy or certificate of health insurance that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, must assign an enrollee under the policy or certificate to a primary care provider if the enrollee or a parent of a minor enrollee has not selected a primary care provider by the 90th day of the plan year. If the insurer assigns the enrollee to a primary care provider, the insurer shall provide notice of the assignment to the enrollee or parent and to the primary care provider. The requirement to provide notice under this subsection does not require an insurer to disclose protected health information if such disclosure would be prohibited under the federal Health Insurance Portability and Accountability Act (HIPAA). (3) An enrollee may select a different primary care provider at any time. (4) Insurers must assign enrollees who are residents of the state of Oregon to an individual or group of individuals who are "primary care providers" in the following hierarchal order: (a) According to the enrollee’s selection. In order to prioritize enrollee choice of a primary care provider, insurers must make all reasonable efforts to communicate with enrollees to complete an initial primary care provider assignment. (b) If the enrollee does not choose a primary care provider, insurers must assign the enrollee to a primary care provider using claim utilization information and the insurer’s assignment methodology that enables the enrollee the best opportunity to access primary care services without unreasonable delay. (c) If the enrollee chooses a primary care provider, but has predominant claim utilization with a different primary care provider, the insurer may communicate with the enrollee the opportunity to select the primary care provider with predominant claim utilization. (d) If the insurer has no information pertinent to enrollee choice or prior utilization, the insurer must assign the enrollee to a primary care provider using the insurer’s assignment methodology that enables the enrollee the best opportunity to access primary care services without unreasonable delay. (5) Insurers must establish a primary care provider assignment correction process that works in partnership with providers to correct inaccurately assigned enrollees.