OAR 836-100-0105: Definitions

(1) “Electronic transaction” means to conduct a transaction: (a) Through the use of a computer program or an electronic or other automated means independently to initiate an action or respond to electronic records or performances in whole or in part, without review or action by an individual; or (b) Through the use of a web portal or the internet. (2)(a) “Health care entity” includes: (A) A health care service contractor as required under ORS 750.055; (B) A multiple employer welfare arrangement as required under ORS 750.333; (C) A prepaid managed care health services organization as defined in ORS 414.736; (D) Any entity licensed as a third party administrator under ORS 744.702; (E) Any person or public body that either individually or jointly established a self-insurance plan, program or contract, including but not limited to persons and public bodies that are otherwise exempt from the Insurance Code under ORS 731.036; (F) A health care clearinghouse or other entity that processes or facilitates the processing of health care financial and administrative transactions from a nonstandard format to a standard format; and (G) Any other person identified by the department that processes health care financial and administrative transactions between a health care provider and an entity described in this subsection. (b) “Health care entity” does not include a pharmacy or a pharmacy benefits manager. (3) “Health insurer” means any insurer authorized to transact health insurance in Oregon. (4) “Oregon Companion Guide” means one of the compilations of uniform standards adopted by the Department of Consumer and Business Services and posted on the Oregon Division of Financial Regulation’s website that provide standards for health care financial and administrative transactions. The following Oregon Companion Guides are applicable to respective transactions with health insurers and health care entities in Oregon: (a) Oregon Companion Guide for the Implementation of the ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271). (b) Oregon Companion Guide for the Implementation of the ASC X12/005010X212: Claim Status Request and Response (276/277). (c) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12N/005010X221 Health Care Claim Payment/Advice (835). (d) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X222 Health Care Claim: Professional (837). (e) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X223 Health Care Claim: Institutional (837). (f) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X224 Health Care Claim: Dental (837). (5) “Oregon Companion Guide Oversight Committee” means the committee appointed jointly by the Department of Consumer and Business Services and the Oregon Health Authority to carry out the responsibilities under OAR 836-100-0120. (6) “Provider” means a health care provider that provides health care or medical services within Oregon for a fee and is eligible for reimbursement for these services.