Or. Admin. Code § 410-141-3890 - Grievances & Appeals: Appeal Process
(1) A member, member representative, or
provider with the member's written consent, may file an oral or written appeal
with the Managed Care Entity (MCE) to:
(a)
Express disagreement with an adverse benefit determination; or
(b) Oral appeals timeframes shall begin when
there is established contact made between the member and an MCE representative.
If the member leaves a voice mail message with the MCE indicating that they
wish to appeal a denial the MCE shall make reasonable efforts (multiple calls
at different times of day) to reach the member by phone to get the details of
the service they wish to appeal. The MCE shall document each attempt to reach
the member (date(s) and time(s)) by phone and make note of the date they
establish contact with the member and are able to attain the appeal information
needed to process the appeal.
(2) Each MCE may have only one level of
appeal for members, and members shall complete the appeals process with the MCE
prior to requesting a contested case hearing.
(3) For standard resolution of an appeal and
notice to the affected parties, the MCE shall establish a timeframe that is no
longer than 16 days from the day the MCE receives the appeal:
(a) If an MCE fails to adhere to the notice
and timing requirements in 42 CFR §
438.408, the member
is considered to have exhausted the MCE's appeals process. In this case, the
member may initiate a contested case hearing;
(b) The MCE may extend the timeframes from
section (3) of this rule by up to 14 days if:
(A) The member requests the extension;
or
(B) The MCE shows to the
satisfaction of the Authority upon its request that there is need for
additional information and how the delay is in the member's interest.
(c) If the MCE extends the
timeframes but not at the request of the member, the MCE shall:
(A) Make reasonable efforts (including as
necessary multiple calls at different times of day) to give the member prompt
oral notice of the delay;
(B)
Within two (2) days, give the member written notice of the reason for the
decision to extend the timeframe and inform the member of the right to file a
grievance if the member disagrees with that decision;
(C) Resolve the appeal as expeditiously as
the member's health condition requires and no later than the date the extension
expires.
(4)
For expedited resolution of an appeal please see OAR
410-141-3895. A request for an
expedited appeal for a service that has already been provided to the member
(post-service) shall not be granted. The MCE shall transfer the appeal to the
timeframe for standard resolution as set forth above section (3) of this
rule.
(5) For purposes of this
rule, an appeal includes a request from the Authority to the MCE for review of
a notice.
(6) A member or the
provider on the member's behalf may request an appeal either orally or in
writing directly to the MCE for any notice or failure to act within the
timeframes provided in 42
CFR §
438.408 (a)
regarding the standard resolution of appeals by the MCE:
(a) The MCE shall ensure oral requests for
appeal of a notice are treated as appeals to establish the earliest possible
filing date;
(b) The member shall
file the appeal with the MCE no later than 60 days from the date on the
notice.
(7) Parties to
the appeal include, as applicable:
(a) The
member and their representative; or
(b) The legal representative of a deceased
Member's estate.
(8) The
MCE shall resolve each standard appeal in time period defined above in section
(4) of this rule. The MCE shall provide the member with a notice of appeal
resolution as expeditiously as the member's health condition requires, or
within 72 hours for matters that meet the requirements for expedited appeals in
OAR 410-141-3895.
(9) If the MCE or the Administrative Law
Judge reverses a decision to deny, limit, or delay services that were not
furnished while the appeal was pending, the MCE shall authorize or provide the
disputed services promptly and as expeditiously as the member's health
condition requires but no later than 72 hours from the date it receives notice
reversing the determination. The MCE must take the following steps:
(a) notify the Member, the member's
representative (if applicable) both orally and in writing and the member's
provider in writing of the available services and how to access them;
(b) Enter the prior authorization into the
system or adjust the encounter data claim representing the service.
(10) If the MCE or the
Administrative Law Judge reverses a decision to deny authorization of services,
and the member received the disputed services while the appeal was pending, the
MCE or the State shall pay for those services in accordance with the Authority
policy and regulations.
(11) The
written notice of appeal resolution shall be in a format approved by the
Authority. The notice shall contain, as appropriate, the same elements as the
notice of adverse benefit determination, as specified in OAR
410-141-3885, in addition to:
(a) The date the member filed the appeal with
the MCE;
(b) The results of the
resolution process and the date the MCE completed the resolution;
(c) Effective date of the appeal
decision;
(d) For appeals resolved
partially or wholly in favor of the member, an explanation that the member may
now access those benefits that were denied and how to do so; and
(e) For appeals not resolved wholly in favor
of the member:
(A) Reasons for the resolution
and a reference to the particular sections of the statutes and rules involved
for each reason identified in the Notice of Appeal Resolution relied upon to
deny the appeal;
(B) The right to
request a contested hearing or expedited hearing with the Authority and how to
do so;
(C) The right to request to
continue receiving benefits while the hearing is pending and how to do so;
and
(D) An explanation that the
member may be held liable for the cost of those benefits if the hearing
decision upholds the MCE's adverse benefit determination;
(E) Copies of the appropriate forms: Request
to Review a Health Care Decision Appeal and Hearing Request form (OHP 3302) or
approved facsimile.
(f)
For appeals resolved partially or wholly in favor of the member an explanation
that the member may now access those benefits that were denied and how to do
so.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
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