OAR 836-053-1410: Procedures

(1) An insurer must allocate covered procedures or services to the categories established in ORS 743.874(3) and 743.876(3) in a manner that will enable the insurer to provide a reasonable estimate of an enrollee’s share of costs for a procedure or service. An insurer must determine its allocation according to its Oregon block of business at least once every 12 months to ensure that the procedures and services are currently the most common procedures in the categories. (2) When an insurer provides a combined estimate for two or more procedures or services, the insurer must apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. With the estimate provided under this section, he insurer must disclose to the enrollee that the estimate includes the costs of two or more procedures or services. (3) With any estimate, an insurer must disclose whether the estimate applies only to those costs specifically relating to the procedure or service, such as is given in commonly used procedure codes, or applies to an episode of care that includes the procedure or service and its related costs. (4) As required by the director, an insurer must file the following information for the purpose of assessing the effect of the disclosure requirements in ORS 743.874 and 743.876: (a) The number of requests for estimates under ORS 743.874 and 743.876 received by the insurer in a calendar year; and (b) Of the requests in paragraph (a) of this subsection, the number of requests for in-network procedures and services and the number of requests for out-of-network procedures and services.