Or. Admin. Code § 410-141-3915 - Grievances & Appeals: System Recordkeeping

(1) Each MCE shall maintain records of grievances, appeals, Notices of Adverse Benefit Determinations (NOABDs) and prior authorizations and shall review the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the state quality strategy as stated in 42 CFR 438.416 and in alignment with contractual requirements.

(2) Consistent with record retention requirements in OAR 410-141-3520, MCEs must maintain yearly logs of all appeals, grievances, NOABDs and prior authorizations for 10 years, which must include information about the reasons for each grievance, appeal, NOABD and prior authorization denial, as well as the resolution and supporting reasoning.

(3) The MCE must review the log monthly for completeness, accuracy, and compliance with required procedures.

(4) MCEs shall submit for the Authority's review the Grievance and Appeals Log, samples of NOABDs, prior authorization documentation and other reports as required under the MCE contract.

(5) The Grievance System Report and Grievance and Appeals Log shall be forwarded to the MCE's Quality Improvement committee to comply with the Quality Improvement standards as follows:

(a) Review of completeness, accuracy, and timeliness of documentation;

(b) Compliance with written procedures for receipt, disposition, and documentation; and

(c) Compliance with applicable OHP rules.

Notes

Or. Admin. Code § 410-141-3915

DMAP 57-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 28-2021, amend filed 06/28/2021, effective 7/1/2021; DMAP 143-2024, amend filed 12/29/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & 414.727