Oregon Law
Law as of Jan 1, 2026
Chapter contents
743B.001Definitions 743B.003Purposes 743B.005Definitions 743B.010Issuance of group health benefit plan to affiliated group of employers; determination of number of employees for purpose of determining eligibility as small employer 743B.011Group health benefit plans subject to provisions of specified laws; exemptions 743B.012Requirement to offer all health benefit plans to small employers; offering of plan by carriers; exceptions 743B.013Requirements for small employer health benefit plans 743B.020Eligible employees and small employers; rules 743B.100Department’s authority to regulate market 743B.102Certifications and disclosure of coverage 743B.103Use of health-related information 743B.104Coverage in group health benefit plans; consideration of prospective enrollee health status restricted; effect of discontinuing offer of plans; exceptions; coverage by multiple employer welfare arrangements 743B.105Requirements for group health benefit plans other than small employer plans 743B.109Short term health insurance policies; rules 743B.110Implementation of federal laws; rules 743B.120[Formerly 743.764; 2017 c.152 §10; renumbered 743A.262 in 2017] 743B.125Individual health benefit plans; waiting or exclusion periods; preexisting condition exclusions; guaranteed issue and renewal 743B.126Carrier marketing of individual health benefit plans; rules; duties of carrier regarding applications; effect of discontinuing offer of plans 743B.127Rules for ORS 743.022, 743B.125 and 743B.126 743B.128Exceptions to requirement to actively market all plans 743B.129Shortening period of exclusion following discontinued offering; rules 743B.130Requirement to offer bronze and silver plans; rules 743B.195Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996 743B.197Health Care Consumer Protection Advisory Committee 743B.200Requirements for insurers offering managed health insurance; quality assessment 743B.202Requirements for insurers offering managed health or preferred provider organization insurance; rules; opportunity to participate 743B.204Required managed health insurance contract provision; enrollee liability 743B.206[Formerly 743.831; repealed by 2017 c.101 §53 and 2017 c.384 §13] 743B.220Requirements for insurers that require designation of participating primary care physician; exceptions 743B.221Assignment of beneficiaries to primary care providers; rules 743B.222Designation of women’s health care provider as primary care provider; direct access to women’s health care provider 743B.225Continuity of care 743B.227Referrals to specialists 743B.250Required notices to applicants and enrollees; grievances, internal appeals and external reviews; reports to department 743B.252External review; rules 743B.253Director to contract with independent review organizations to provide external review; rules 743B.254Required statements regarding external reviews 743B.255Enrollee application for external review; when enrollee deemed to have exhausted internal appeal 743B.256Duties of independent review organizations; expedited reviews 743B.257Civil penalty for failure to comply by insurer that agreed to be bound by decision 743B.258Private right of action 743B.260Claims and appeals of adverse benefit determinations under disability income insurance policies; rules 743B.275Definitions for ORS 743B.275 to 743B.285 743B.277Credits to deductibles and out-of-pocket expenses; requirements; process 743B.280[Formerly 743B.871; renumbered 743B.275 in 2025] 743B.281Estimate of costs for in-network procedure or service 743B.282Estimate of costs for out-of-network procedure or service 743B.283Submission of methodology used to determine insurer’s allowable charges 743B.284Alternative mechanism for disclosure of costs and charges 743B.285Rules 743B.287Balance billing prohibited for health care facility services 743B.288Balance billing prohibited for labor and delivery services rendered by out-of-network provider to which insured was diverted during public health emergency 743B.290Hospital payment of copayment or deductible for insured patient 743B.292Balance billing prohibited for ground ambulance services; health benefit plan reimbursement rate requirements; reporting and database of established local rate; rules; penalties 743B.300Disclosure of differences in replacement health insurance policies; nonduplication for persons 65 and older; rules 743B.310Rescinding coverage; permissible bases; notice; rules 743B.320Minimum grace period; notice upon termination of policy; effect of failure to notify 743B.321Applicability of ORS 743B.320 743B.323Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium; rules 743B.324Rules for certain notice requirements 743B.330Notice to policyholder required for cancellation or nonrenewal of health benefit plan; effect of failure to give notice 743B.340When group health insurance policies to continue in effect upon payment of premium by insured individual 743B.341Continuation of benefits after termination of group health insurance policy; rules 743B.342Continuation of benefits after injury or illness covered by workers’ compensation 743B.343Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older 743B.344Procedure for obtaining continuation of coverage under ORS 743B.343 743B.345Premium for continuation of coverage under ORS 743B.344; termination of right to continuation 743B.347Continuation of coverage under group policy upon termination of membership in group health insurance policy; applicability of waiting period to rehired employee 743B.400Decisions regarding health care facility length of stay, level of care and follow-up care 743B.403Insurer prohibited practices; patient communication and referral 743B.405Medical services contract provisions; nonprovider party prohibitions; future contracts 743B.406Vision care providers 743B.407Naturopathic physicians 743B.420Prior authorization requirements 743B.422Utilization review requirements for medical services contracts to which insurer not party; right to appeal 743B.423Utilization review requirements for insurers offering health benefit plan 743B.424Applicability 743B.425Prohibited restrictions on coverage of treatment for opioid or opiate withdrawal, post-exposure and preexposure prophylactic antiretroviral drugs and drugs for treatment of human immunodeficiency virus or acquired immunodeficiency syndrome; exceptions 743B.427Nonquantitative treatment limitations on coverage of behavioral health conditions; carrier reporting requirements; confidentiality; summary annually reported to legislative committees 743B.430Prohibited restrictions on prior authorization requirements for surgical procedures 743B.445Application programming interface; requirements 743B.450Prompt payment of claims; limits on use of electronic payment methods; rules 743B.451Refund of paid claims 743B.452Interest on unpaid claims 743B.453Underpayment of claims 743B.454Claims submitted during credentialing period 743B.456Limits on use of electronic payment methods for reimbursement of dental claims 743B.458Performance-based incentive payments for primary care 743B.460Conditions for restricting payments to only in-network providers 743B.462Direct payments to providers 743B.470Medicaid not considered in coverage eligibility determination; claims for services paid for by medical assistance; prohibited ground for denial of enrollment of child; insurer duties 743B.475Guidelines for coordination of benefits; rules 743B.500Selling and leasing of provider panels by contracting entity; definitions 743B.501Registration of contracting entity 743B.502Third party contracts for leasing of provider panels; requirements 743B.503Additional requirements for third party contracts 743B.504Third party contracts for dental care services 743B.505Provider networks; rules 743B.550Disclosure of information 743B.555Confidential communications 743B.601Synchronization of prescription drug refills 743B.602Step therapy 743B.603Out-of-pocket maximums, deductibles, copayments, coinsurance and cost-sharing 743B.607Nonopioid prescription drug coverage requirements 743B.610Clinician-administered drugs for treatment of cancer 743B.800Risk adjustment procedures; rules 743B.810Enrollees covered by workers’ compensation

Chapter 743B — Health Benefit Plans: Individual and Group

ORS 743B.420 Prior authorization requirements

Except in the case of misrepresentation, prior authorization determinations shall be subject to the following requirements:

(1)

Prior authorization determinations relating to benefit coverage and medical necessity shall be binding on the insurer if obtained no more than 60 days prior to the date the service is provided.

(2)

Prior authorization determinations relating to enrollee eligibility shall be binding on the insurer if obtained no more than five business days prior to the date the service is provided.

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Provenance

Version history

2026-01-01

2025 Oregon Revised Statutes — official online source