OAR 836-053-1404: Definitions; Noncontracting Providers; Co-Morbidity Disorders

(1) As used in ORS 743A.168 and OAR Chapter 836: (a) “Behavioral health condition” means any mental or substance use disorder covered by diagnostic categories listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), the International Classification of Diseases, 10th Revision (ICD-10), or the International Classification of Diseases, 11th Revision (ICD-11). (b) “Generally accepted standards of care” means; (A) Standards of care and clinical practice guidelines that: (i) Are generally recognized by health care providers practicing in relevant clinical specialties; and (ii) Are based on valid, evidence-based sources; and (B) Products and services that: (i) Address the specific needs of a patient for the purpose of screening for, preventing, diagnosing, managing or treating an illness, injury or condition or symptoms of an illness, injury or condition; (ii) Are clinically appropriate in terms of type, frequency, extent, site and duration; and (iii) Are not primarily for the economic benefit of an insurer or payer or for the convenience of a patient, treating physician or other health care provider. (c) “Valid, evidence-based sources” includes but is not limited to: (A) Peer-reviewed scientific studies and medical literature; (B) Recommendations of nonprofit health care provider professional associations, and; (C) Specialty societies. (2) A non-contracting provider must cooperate with a health insurer's requirements for review of treatment in ORS 743A.168(2) and (3) to the same extent as a contracting provider in order to be eligible for reimbursement. (3) The exception of a disorder in the definition of "behavioral health condition” in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder.