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Managed care organization reporting requirements

A managed care organization (MCO) must provide the Department of Consumer and Business Services (DCBS) director with a copy of any MCO/insurer contract agreement, signed by both the insurer and the MCO, within 30 days of execution of the contract. Contract amendments, addendums, and cancellations must also be submitted to the director within 30 days of execution.

When an MCO/insurer contract agreement contains a specific expiration or termination date, the MCO must provide the director with a copy of a contract extension, signed by both the insurer and MCO, no later than the contract's date of expiration or termination. Workers are not subject to an expired or terminated managed care contract [see ORS 656.245(4)(a) and OAR 436-010-0275(13)].

When an MCO amends its certified plan, it must first submit the plan amendment to the director for review and approval before taking any action based on the amendment.

Annual reports are submitted to the director of DCBS containing: (a) a summary of any sanctions or punitive actions taken by the MCO against its members; (b) a summary of actions taken by the MCO's peer review committee; and (c) an affidavit that the approved MCO plan is consistent with the MCO's business practices, and that any amendments to the plan have been approved by the director. As part of their annual report, MCOs are required to include information concerning any decisions they make which deny a worker's ability to continue treatment with a qualified off-panel provider, after the worker's claim has been enrolled into the MCO.

On a quarterly basis, each MCO must provide the director with data regarding its panel provider membership.

 


Questions? Contact us at 503-947-7606 or e-mail wcd.medicalquestions@state.or.us.