Utilization Review Licensing in Oregon

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Oregon. For assistance with licensing, please contact us to learn about our software and managed license services.

Oregon External Review Summary

Type of Review:

Medical Utilization Review

Agency:Oregon Division of Financial Regulation
Notes:

There is no external review license in Oregon, but external review organizations must submit an annual summary to the division each year.

Initial Registration

Agency:Oregon Division of Financial Regulation
Form:

External Review Annual Summary

Agency fee:

$0

Registration Renewal

Agency:Oregon Division of Financial Regulation
Form:

External Review Annual Summary

Agency fee:

$0

Due:

Annually by March 31.

Oregon Utilization Review Summary

Type of Review:

Medical Utilization Review

Agency:Oregon Division of Financial Regulation
Notes:

There is no utilization review license in Oregon, but review organizations must submit an annual summary to the division each year.

Initial Registration

Agency:Oregon Division of Financial Regulation
Form:

Utilization Review Annual Summary

Agency fee:

$0

Registration Renewal

Agency:Oregon Division of Financial Regulation
Form:

Utilization Review Annual Summary

Agency fee:

$0

Due:

Annually by June 30.

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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