1. (1) As used in ORS 743A.168 and OAR Chapter 836:

   1. (a) “Behavioral health condition” means any mental or substance use disorder covered by diagnostic categories listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), the International Classification of Diseases, 10th Revision (ICD-10), or the International Classification of Diseases, 11th Revision (ICD-11).

   2. (b) “Generally accepted standards of care” means;

      1. (A) Standards of care and clinical practice guidelines that:

         1. (i) Are generally recognized by health care providers practicing in relevant clinical specialties; and
         2. (ii) Are based on valid, evidence-based sources; and

      2. (B) Products and services that:

         1. (i) Address the specific needs of a patient for the purpose of screening for, preventing, diagnosing, managing or treating an illness, injury or condition or symptoms of an illness, injury or condition;
         2. (ii) Are clinically appropriate in terms of type, frequency, extent, site and duration; and
         3. (iii) Are not primarily for the economic benefit of an insurer or payer or for the convenience of a patient, treating physician or other health care provider.
         4. (c) “Valid, evidence-based sources” includes but is not limited to:
      3. (A) Peer-reviewed scientific studies and medical literature;
      4. (B) Recommendations of nonprofit health care provider professional associations, and;
      5. (C) Specialty societies.
2. (2) A non-contracting provider must cooperate with a health insurer's requirements for review of treatment in ORS 743A.168(2) and (3) to the same extent as a contracting provider in order to be eligible for reimbursement.
3. (3) The exception of a disorder in the definition of "behavioral health condition” in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder.

Statutory/Other Authority

ORS 731.244 & ORS 743A.168

Statutes/Other Implemented

ORS 743A.168

History

ID 8-2022, amend filed 12/22/2022, effective 01/01/2023
ID 5-2016, f. & cert. ef. 4-26-16
ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16
ID 3-2015, f. & cert. ef. 5-12-15
ID 19-2014(Temp), f. & cert. ef. 11-14-14 thru 5-12-15
ID 3-2013, f. 6-10-13, cert. ef. 6-17-13
ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13
ID 13-2006, f. 7-14-06 cert. ef. 1-1-07