OR DFR Bulletin 2007-07: Annual Reporting Procedures for Patient Protection Act reports on Grievances, Utilization Review, Quality Assessment and Networking Adequacy

OREGON INSURANCE DIVISION BULLETIN INS 2007-7 DATE: December 18, 2007 TO: All Health Insurers, Health Care Service Contractors, Self-insured MEWAs and Self-insured Public Entities RE: Annual Reporting Procedures for Patient Protection Act reports on Grievances, Utilization Review, Quality Assessment and Networking Adequacy This bulletin supersedes INS 2007-2. Background The purpose of this bulletin is to provide instructions that will facilitate the annual reporting of grievances, utilization review policies, quality assessment activities and network adequacy. The corresponding reporting requirements are specified in ORS 743.804, 743.807, 743.814, and 743.817 and in OAR 836-053-1000, 836-053-1070, 836-053-1130, 836-053-1170 and 836-053- 1190. Deadline All reports are to be received by the Insurance Division on or before 5:00 p.m. (Pacific Daylight Time) on June 30 of each year with the previous calendar year’s data. Reports required All insurers offering a health benefit plan as defined by ORS 743.730 are required to submit the following annual reports, subject to any special criteria noted below: ♦ Grievance Annual Report. (See OAR 836-053-1070 for details on content.) ♦ Utilization Review Annual Summary, if the insurer provides utilization review as defined by ORS 743.801 or has utilization review provided on its behalf. (See OAR 836-053-1130 for details on content.) ♦ Quality Assessment Annual Summary, if the insurer offers managed health insurance as defined by ORS 743.801. (See OAR 836-053-1170 for details on content.) ♦ Network Adequacy Annual Summary, if the insurer offers managed health insurance as defined by ORS 743.801 or preferred provider organization insurance as defined by ORS 743.801. (See OAR 836-053-1190 for details on content.) Department of Consumer and Business Services Insurance Division 350 Winter St. NE, Room 440 PO Box 14480 Salem, OR 97301-0405 AR 836-053-1170 for details on content.) ♦ Network Adequacy Annual Summary, if the insurer offers managed health insurance as defined by ORS 743.801 or preferred provider organization insurance as defined by ORS 743.801. (See OAR 836-053-1190 for details on content.) Department of Consumer and Business Services Insurance Division 350 Winter St. NE, Room 440 PO Box 14480 Salem, OR 97301-0405 (503) 947-7980 FAX (503) 378-4351 TTY (503) 947-7280 www.oregoninsurance.org Theodore R. Kulongoski, Governor 2 Note: Insurers not domiciled in Oregon are not subject to the above requirements if they transacted less than $2 million in annual health benefit plan premium in Oregon during the report year. (See OAR 836-053-1000(1)) Procedures 1. Insurers must submit all required reports in rich text, PDF, or Word format. 2. Insurers must submit reports via e-mail to: ins.mrktsurv@state.or.us. 3. IMPORTANT: Each document title and each e-mail subject line must contain: The insurer name / the year / and report type(s) (underlined for clarification only), Example: “Company Z 2002 Grievances, UR, NA & QA" (underlined for clarification only). 4. Hard copy (paper) submission is no longer required. 5. When an insurer has experienced no change in reported data from one year to the next, the insurer may submit as its report a report with the following statement: “Same data as in the ______ report.” (Fill in year of the report.) This statement may be submitted up to two years in a row; however, at least every fourth year the insurer must submit a complete report as outlined in the OARs above. (OAR 836-053-1000(5)). 6. Required forms and certification statements are available online at www.cbs.state.or.us/ins/insurer/financial_regulation/app_forms-alpha.html. Effective date This bulletin takes effect immediately. Signed this 18th day of December 2007. _____________(Signed)_____________ Carl N. Lundberg Acting Insurance Administrator