Or. Admin. Code § 410-141-3900 - Grievances And Appeals: Contested Case Hearings
(1) A Managed Care Entity (MCE) shall have a
system in place to ensure its members and providers have access to appeal for
MCE's action by requesting a contested case hearing:
(a) Contested case hearings are conducted
pursuant to ORS 183.411 to
183.497 and the Attorney
General's Uniform and Model Rules of Procedure for the Office of Administrative
Hearings, OAR 137-003-0501 to
137-003-0700. Processes for
contested case hearings are provided in OAR
410-120-1860 Contested Case
Hearing Procedures;
(b) If a
provider filed an appeal on behalf of a member, as permitted in OAR
410-141-3890, the provider may
subsequently request a contested case hearing on behalf of the member in
accordance with the procedures in this rule;
(c) Appeals brought on the provider's own
behalf are not subject to this rule, which governs appeals brought by member or
by a provider on the member's behalf but are governed by OAR
410-120-1560.
(2) The member may not proceed to
a hearing without first completing an appeal with their MCE and receiving
written notice that the MCE adverse benefit determination is upheld, subject to
the exception under section (3) of this rule, below:
(a) The member shall file a hearing request
with the Authority using form OHP 3302 or any other Oregon Health Authority
(Authority)-approved appeal or hearing request form no later than 120 days from
the date of the MCE's notice of appeal resolution. The Authority shall consider
the request timely with the exception as noted for expedited hearing requests
in OAR 410-141-3905;
(b) If the member sends a contested case
hearing request directly to the Authority and the Authority determines that the
member qualifies for a contested case hearing, the MCE shall submit the
required documentation to the Authority's Hearings Unit within two (2) business
days of the Authority's request;
(c) If the member files a request for an
appeal or contested case hearing with the Authority prior to the member filing
an appeal with the MCE, and if the request does not satisfy section (3) below,
the Authority shall transfer the request to the MCE and provide notice of the
transfer to the member. The MCE shall:
(A)
Review the request immediately as an appeal of the MCE's notice of adverse
benefit determination;
(B) Respond
to the request for the appeal within 16 days and provide the member with a
notice of appeal resolution.
(d) If a member sends the contested case
hearing request to the MCE after the MCE has already completed the initial plan
appeal, the MCE shall:
(A) Date-stamp the
hearing request with the date of receipt; and
(B) Submit the following required
documentation to the Authority within two business days:
(i) A copy of the hearing request notice of
adverse benefit determination, and notice of appeal resolution;
(ii) All documents and records the MCE relied
upon to take its action, including those used as the basis for the initial
action or the notice of appeal resolution, if applicable, and all other
relevant documents and records the Authority requests as outlined in detail in
OAR 141-410-3890.
(3) If, after a member properly files an
appeal, the MCE fails to adhere to the notice and timing requirements in
42 CFR §
438.408, the Authority may consider the
member to have exhausted the MCE's appeals process for purposes of requesting a
contested case hearing, as provided in OAR
410-141-3890(3).
The Authority shall notify the MCE of the Authority's decision to allow the
member access to a contested case hearing.
(4) Effective February 1, 2012, the method
described in OAR 137-003-0520(8)-(10)
is used in computing any period of time prescribed in OAR chapter 410,
divisions 120 and 141 applicable to timely filing of requests for hearing.
However, due to operational conflicts, the procedures needing revision, and the
expense of doing so, the provisions in OAR
137-003-0520(9)
and 137-003-0528(2)
that allow hearing requests to be treated as timely based on the date of
postmark do not apply to MCE member contested case hearing requests.
(5) The parties to a contested case hearing
include, as applicable:
(a) The member and
their representative; or
(b) The
legal representative of a deceased Member's estate; and
(c) The MCE.
(6) The Authority shall refer the hearing
request along with the notice of adverse benefit determination or notice of
appeal resolution to the Office of Administrative Hearings (OAH) for hearing.
Contested case hearings are requested using Authority form MSC 443 or other
Authority-approved appeal or hearing request forms.
(7) The Authority shall issue a final order,
or the Authority shall resolve the case ordinarily within ninety (90) days from
the date the MCE receives the member's request for appeal. The ninety (90)day
count does not include the days between the date the MCE issued a notice of
appeal resolution and the date the member filed a contested case hearing
request.
(8) For reversed hearing
resolution services:
(a) For services not
furnished while the appeal or hearing is pending. If 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.
(b) For services furnished while
the appeal or hearing is pending. If 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.
(c) Any party to the
hearing can file written exceptions or present argument to the Proposed and
Final Order within ten working days after the date the Proposed Order is issued
by the ALJ (see OAR 410-120-1860). If written
exceptions are filed the Order does not become a Final Order on the 11th work
day and the services shall not be provided until the Final Order is issued by
OHA. Once a Final Order is issued and if the decision remains overturned the
services shall be authorized or provided to the member within 72 hours of the
MCE receiving the Final Order.
Notes
Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
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