Or. Admin. Code § 410-141-3550 - Resolving Disputes between MCEs and the Authority

(1) If an MCE has a dispute with the Authority as a result of a decision that is perceived as adversely affecting an MCE, the MCE may submit a request to the Director of the Authority, or the Director's designee, requesting an Administrative Review, as prescribed in OAR 410-120-1580.

(a) These disputes primarily address legal or policy issues that may arise in the context of an Authority decision that is perceived by the MCE to adversely affect the MCE and is not otherwise reviewed as a claim redetermination, a contested case, or client appeal. An example of such disputes includes, but is not limited to, Authority decisions made through the OHA Provider Discrimination Review Process as a result of a provider discrimination appeal;

(b) This rule does not address claims that the Authority has breached its contract with an MCE;

(c) This MCE process is not mandatory, and it need not be exhausted before an MCE seeks judicial review or brings any other form of action related to any MCE/Authority dispute related decision.

(2) Within 30 calendar days of the conclusion of the administrative review, or such other time as may be agreed to by the MCE and the Authority, the Authority shall send written results of the administrative review to the initiating MCE and any other affected MCE. Should a resolution be reached through administrative review that is mutually agreeable to all involved, the process shall be considered complete and binding.

(3) If the dispute between the MCE and the Authority remains unresolved as a result of the administrative review, the CCO may request an alternative dispute resolution as set forth below to attempt to resolve the issue. The alternative dispute process is conducted pursuant to the Attorney General's Uniform Model Rules OAR 137-005-0060 and 137-005-0070.

(4) Not more than 10 business days after receipt of the final administrative review decision, the MCE may contact the Director of the Authority indicating the MCE's intent to pursue mediation. In that request, the MCE may request to stay the administrative review decision, which the Authority will grant if the MCE alleges sufficient facts and provides good cause for the stay as provided in OAR 137-004-0090. The Authority shall respond within 10 business days of the date of the stay request.

(5) After both the MCE and the Authority agree to enter into mediation, both shall attempt to agree on the selection of the mediator and complete paperwork required to secure the mediator's services. If the MCE and the Authority are unable to agree on the selection of a mediator, both shall appoint a mediator, and those mediators shall select the final mediator. To be qualified to propose resolutions for disputes under this rule, the mediator shall:

(a) Be a knowledgeable and experienced mediator;

(b) Be familiar with health care and the disputed matters; and

(c) Follow the terms and conditions specified in this rule for the mediation process.

(6) If the dispute is likely to impact another MCE, the Authority shall notify all MCEs potentially impacted by the dispute and provide an opportunity for the impacted MCEs to participate in the dispute resolution process. MCEs that opt into the process have, from that time forward, the same rights and responsibilities as the MCE that initiated the dispute.

(7) The MCE and the Authority shall share in the cost of all mediation expenses, whether the dispute is resolved or not.

(8) Within 10 business days of a selection of a mediator or upon a different schedule, as agreed to by the parties and the mediator, the MCE and the Authority shall submit to each other and to the mediator the following:

(a) Dispute resolution offer; and

(b) Explanation of their position, i.e., advocacy brief.

(9) The parties will engage in mediation as arranged by the mediator.

(10) The Authority shall maintain the confidentiality of proprietary information of all participating MCEs to the extent the information is protected under state or federal law.

Notes

Or. Admin. Code § 410-141-3550

DMAP 55-2019, adopt filed 12/17/2019, effective 1/1/2020

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 413.042, ORS 183.484 & 183.502