Or. Admin. Code § 410-120-1560 - Provider Appeals
(1) For
purposes of Division provider appeal rules in chapter 410, division 120, the
following terms and definitions are used:
(a)
"Provider" means an individual or entity enrolled with the Division or under
contract with the Division that is subject to the Division rules and that has
requested an appeal in relation to health care, items, drugs, or services
provided or requested to be provided to a client on a fee-for-service basis or
under contract with the Division where that contract expressly incorporates
these rules;
(b) "Provider
Applicant" means an individual or entity that has submitted an application to
become an enrolled provider with the Division, but the application has not been
approved;
(c) "Prepaid Health Plan"
has the meaning set forth in OAR
410-141-3500, except to the
extent that Mental Health Organizations (MHO) have separate procedures
applicable to provider grievances and appeals;
(d) "Prepaid Health Plan provider" means an
individual or entity enrolled with the Division but that provided health care
services, supplies or items to a client enrolled with a PHP, including both
participating providers and non-participating providers as those terms are
defined in OAR 410-141-0000, except that
services provided to a client enrolled with an MHO shall be governed by the
provider grievance and appeal procedures administered by the Authority's
Addictions and Mental Health Division;
(e) The "Provider Appeal Rules" refers to the
rules in OAR 410-120-1560 to
410-120-1600, describing the
availability of appeal procedures and the procedures applicable to
each;
(f) "Non-participating
provider" has the meaning set forth in OAR
410-141-3500;
(g) Coordinated Care Organization (CCO) has
the meaning set forth in OAR
410-141-3500.
(2) A Division enrolled provider
may appeal a Division decision in which the provider is directly adversely
affected including but not limited to the following:
(a) A denial or limitation of payment allowed
for services or items provided;
(b)
A denial related to an NCCI edit;
(c) A denial of provider's application for
new or continued participation in the Medical Assistance Program; or
(d) Sanctions imposed, or intended to be
imposed, by the Division on a provider or provider entity; and
(e) Division overpayment determinations made
under OAR 410-120-1397.
(4) A provider appeal is initiated by filing
a timely request in writing for review with the Division:
(a) A provider appeal request is not required
to follow a specific format as long as it provides a clear written expression
from a provider or provider applicant expressing disagreement with a Division
decision or from a CCO or PHP provider expressing disagreement with a decision
by a CCO or PHP.
(b) The request
must identify the decision made by the Division, a CCO, or PHP that is being
appealed and the reason the provider disagrees with that decision.
(c) A provider appeal request is timely if it
is received by the Division:
(A) Within 180
calendar days from the date of the Division's fee-for-service
decision;
(B) Within 30 calendar
days from the date of the CCO or PHP decision after the provider completes the
CCO or PHP appeal process.
(5) Types and methods for provider appeals
are:
(a) Claim redeterminations: A Division
denial of or limitation of payment allowed, including prior authorization
decision, or Division overpayment determination for services or items provided
to a client must be appealed as claim re-determinations under OAR
410-120-1570.
(b) Contested Case: A notice of sanctions
imposed or intended to be imposed, the effect of the notice of sanction is, or
will be, to deny, suspend, or revoke a provider number necessary to participate
in the medical assistance on a provider, or provider applicant is entitled to
appeal under OAR 410-120-1600. A provider that
may appeal a notice of sanction as a contested case may choose to request
administrative review instead of contested case hearing if the provider submits
a written request for administrative review and agrees in writing to waive the
right to a contested case hearing and the Division agrees to review the appeal
as an administrative review.
(c)
Administrative review: All provider appeals of Division decisions not described
in section (5)(a) or (b) of this rule are handled as administrative reviews in
accordance with OAR 410-120-1580, unless the
Division issues an order granting a contested case hearing.
(6) Decisions that adversely
affect a provider may be made by different program areas within the Authority:
(a) Decisions issued by the Office of Payment
Accuracy and Recovery (OPAR) or the Authority information security office shall
be appealed in accordance with the process described in the notice;
(b) Other program areas within the Authority
that have responsibility for administering medical assistance funding, such as
nursing home care or community mental health and developmental disabilities
program services, may make decisions that adversely affect a provider. Those
providers are subject to the provider grievance or appeal processes applicable
to those payment or program areas;
(c) Some decisions that adversely affect a
provider are issued on behalf of the Division by Authority contractors such as
the Division pharmacy benefits manager, by entities performing statutory
functions related to the medical assistance programs such as the Drug Use
Review Board, or by other entities in the conduct of program integrity
activities applicable to the administration of the medical assistance programs.
For these decisions made on behalf of the division in which the Division has
legal authority to make the final decision in the matter, a provider may appeal
the decision to the Division as an administrative review, and the Division may
accept the review;
(d) This rule
does not apply to contract administration issues that may arise solely between
the Division and a CCO or PHP. Those issues shall be governed by the terms of
the applicable contract;
(e) The
Division provides limited provider appeals for CCO or PHP providers or
non-participating providers concerning a decision by a CCO or PHP. In general,
the relationship between a CCO or PHP and their providers is a contract matter
between them. Client appeals are governed by the client appeal rules, not
provider appeal rules.
(A) The CCO or PHP
provider seeking a provider appeal must have a current valid provider
enrollment agreement with the Division and, unless the provider is a
non-participating provider, must also have a contract with the CCO or PHP;
and
(B) The CCO or PHP provider or
non-participating provider must have exhausted the applicable appeal procedure
established by the CCO or PHP, and the request for provider appeal must include
a copy of the CCO or PHP written decision that is being appealed and a copy of
any CCO or PHP policy being applied in the appeal; and
(C) The CCO or PHP provider appeal or
non-participating provider appeal from a CCO or PHP decision is limited to
issues related to the scope of coverage and authorization of services under the
OHP, including whether services are included as covered on the Prioritized
List, guidelines, and in the OHP Benefit package. The Division provider appeal
process does not include CCO or PHP payment or claims reimbursement amount
issues, except in relation to non-participating provider matters governed by
Division rule;
(D) A timely
provider request for appeal must be made within 30 calendar days from the date
of the CCO or PHP's decision and include evidence that the PHP was sent a copy
of the provider appeal. In every provider appeal involving a CCO or PHP
decision, the CCO or PHP shall be treated as a participant in the
appeal.
(7)
If a provider's request for appeal is not timely, the Division shall determine
whether the failure to file the request was caused by circumstances beyond the
control of the provider, provider applicant, or CCO or PHP provider. In
determining whether to accept a late request for review, the Division requires
the request to be supported by a written statement that explains why the
request for review is late. The Division may conduct further inquiry as the
Division deems appropriate. In determining timeliness of filing a request for
review, the amount of time that the Division determines accounts for
circumstances beyond the control of the provider is not counted. The Division
may refer an untimely request to the Office of Administrative Hearings for a
hearing on the question of timeliness.
(8) The burden of presenting evidence to
support a provider appeal is on the provider, provider applicant, CCO, or PHP
provider:
(a) Consistent with OAR
410-120-1360, payment on a claim
shall be made only for services that are adequately documented and billed in
accordance with OAR 410-120-1280 and all applicable
administrative rules related to covered services for the client's benefit
package and establishing the conditions under which services, supplies or items
are covered, such as the Prioritized List, medical appropriateness and other
applicable standards;
(b)
Eligibility for enrollment and for continued enrollment is based on compliance
with applicable rules, the information submitted or required to be submitted
with the application for enrollment and the enrollment agreement, and the
documentation required to be produced or maintained in accordance with OAR
410-120-1360.
(9) Provider appeal proceedings,
if any, shall be held in Salem, unless otherwise stipulated to by all parties
and agreed to by the Division.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042
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