OAR 836-053-1425: Definitions for behavioral health benefits reporting

As used in these rules: (1) “Behavioral health benefits” means insurance coverage of mental health treatment and services and substance use disorder treatment and services. (2) “Geographic region” means the regions identified as the specific geographic divisions for Oregon’s individual and small group market as required by OAR 836-053-0465. (3) “Incentive payment” means any compensation arrangement, including but not limited to coordination fees, withholds, bonuses, capitation, or any other compensation, to pay a provider or provider group directly or indirectly. (4) “Median maximum allowable reimbursement rate” means the median of all maximum allowable reimbursement rates, minus incentive payments, paid for each billing code for each provider type during a calendar year. (5) “Partial denial” means the denial and non-reimbursement of portions of a medical claim submitted for services or supplies provided to a covered enrollee as specified in the plan documents. (6) “Time-based office visit” means an in-person office or telehealth visit between a health care provider and a patient in specific increments as determined by the relevant CPT billing code.