OAR 836-080-0085: Annual Report; Sampling

(1) Each insurer shall report to the Director annually on its compliance with Section 2, Chapter 747, Oregon Laws 2001 (Enrolled Senate Bill 894), governing claims received by an insurer from a provider on behalf of an enrollee, according to the requirements of this rule. (2) Not later than March 1 of each year, each insurer shall submit the following to the Director: (a) A count of all claims for which final disposition has been made by the insurer during the immediately preceding calendar year. (b) A count of all claims included in the count in subsection (a) of this section that were each finally disposed of later than the 30th day after the date on which the insurer received the claim. (c) A data file that includes a population list with respect to the claims described in subsection (b) of this section, in the form and manner specified by the Director. (3) The Director shall select a number of sample files from each insurer’s data file submitted under section (2) of this rule, using a methodology determined by the Director to provide a representative and statistically valid sampling of the insurer’s insured population and shall deliver to the insurer the file numbers and the format in which the information required under section (4) of this rule shall be captured and submitted to the Director. (4) Each insurer shall examine each sample selected under section (3) of this rule against its records to determine information requested by the Director. The information shall include but not be limited to the following: (a) The date on which the claim was received; (b) The date on which the insurer requested additional information on the claim; (c) The date on which the insurer received the additional information; (d) The date on which the insurer paid or denied the claim. (e) Whether interest was owed or paid on the claim under section 3, chapter 747, Oregon Laws 2001, or whether the insurer was not required to pay interest as provided in Section 3(2), Chapter 747, Oregon Laws 2001. (f) Whether the claim was paid or denied. For the purpose of this subsection, a claim that is paid in part and denied in part shall be treated as a paid claim. (5) Not later than the 60th day after the date on which an insurer receives the selection of sample files from the Director under section (3) of this rule, the insurer shall submit to the Director a report of its data determined under section (4) of this rule in the format prescribed by the Director. (6) For the purpose of the annual report that is due for calendar year 2002, an insurer shall sample and count only those claims that were submitted to an insurer on or after January 1, 2002 and on or before December 31, 2002.