OR HB4028

Insurers, coordinated care organizations (CCOs), and the Oregon Health Authority must provide behavioral health providers with detailed written documentation requirements for claims, including examples, recoupment triggers, and rules for in-network vs. out-of-network providers

Audits of behavioral health claims are restricted to 12 months after submission (or 6 years for suspected fraud for insurers; 5 years for CCOs/OHA), must be completed within 180 days, must be reviewed by a behavioral health professional, and cannot reverse prior authorization determinations of medical necessity

Insurers and CCOs cannot recoup payments based on clerical errors, cannot charge providers for audit costs, cannot use compensation structures that incentivize auditors to find errors, and must offer repayment plans of up to 3 years when recoupment is required

Carriers must annually report additional behavioral health parity data to the Department of Consumer and Business Services, including criteria used for medical management, number of claims subject to medical management practices, and reimbursement methodology deviations

Audit provisions become operative January 1, 2027; the act takes effect 91 days after the 2026 legislative session adjourns