Communication with Providers Timeline Ramps Up

By Rebecca L. Fey, Attorney at Law

Effective April 1, 2025, an insurer or its representative has only two days to respond to a medical provider’s inquiry about claim status, accepted conditions, or MCO enrollment. This two day timeline excludes weekends and legal holidays as defined by statute.

Importantly, this inquiry must be addressed directly. The rule specifically states the insurer or its representative may not direct the medical provider to obtain an answer from another source.

There is no specific format required for this communication. The rule clarifies the insurer or its representative and the medical provider may agree to communicate by email or other electronic means. Having documentation will be ideal to the extent disputes arise.

Be on the lookout for inquiries about claim status, accepted conditions, or MCO enrollment. Full text of the new rule below.

436-010-0270 Insurer’s Rights and Duties

(4) Communication with Providers.

(a) The insurer or its representative must respond to a medical provider’s inquiry about claim status, accepted conditions, or MCO enrollment within two days, excluding Saturdays, Sundays, and legal holidays listed in ORS 187.010 and 187.020. The insurer or its representative may not refer the medical provider to another entity to obtain an answer.

(b) An insurer or its representative and a medical provider may agree to communicate about claim status, accepted conditions, or MCO enrollment by email or other electronic means. Electronic records sent are subject to the Oregon Consumer Information Protection Act under ORS 646A.600 to 646A.628 and federal law.

As always, please do not hesitate to contact the attorneys at Reinisch Wilson P.C. with any questions.