Or. Admin. R. 410-141-3885 - Grievances & Appeals: Notice of Action/Adverse Benefit Determination

Current through Register Vol. 60, No. 12, December 1, 2021

(1) When an MCE has made an adverse benefit determination, the MCE shall notify the requesting provider and give the member and the member's representative a written notice of action/adverse benefit determination notice. The notice shall:

(a) Comply with the Authority's formatting and readability standards in OAR 410-141-3585 and 42 CFR § 438.10 and be written in plain language sufficiently clear that a layperson could understand the notice and make an informed decision about appealing and following the process for requesting an appeal;

(b) For timing of notices, follow timelines required for the specific service authorization or type via oral and written mechanisms for any service request of the member or the member's provider outlined in OAR 410-141-3835 MCE Service Authorization or otherwise specified in this rule.

(2) The following are notice requirements for pre-service denials:

(a) Meet the content notice requirements specified in 42 CFR § 438.404 and in the MCE contract, including the following information:

(A) MCE contact information and subcontractor contact information including name, address, and telephone number, if applicable, included in the ABD notice excluding any cover pages;

(B) Date of the notice;

(C) Name of the member's Primary Care Practitioner (PCP), Primary Care Dentist (PCD), or behavioral health professional if the member has an assigned practitioner or the most specific information available if a member is not assigned to a practitioner due to the clinic/facility model; If the member has not been assigned a practitioner because they enrolled in the MCE within the last 30 days, the NOABD should state PCP, PCD, BH provider assignment has not occurred.

(D) Member's name, date of birth, address, and OHP member ID number;

(E) Service requested and the adverse benefit determination the MCE intends to make, including whether the MCE is denying, terminating, suspending, or reducing a service;

(F) Date service was requested by the provider or member;

(G) Name of the provider who requested the service;

(H) Effective date of the adverse benefit determination if different from the date of the notice;

(I) Diagnosis and procedure codes submitted with the authorization request including a description in plain language if the MCE is denying a requested service because of line placement on the Prioritized List of Health Services or the diagnosis and procedure code do not pair on the Prioritized List;

(J) Whether the MCE considered other conditions such as co-morbidity factors if the service was below the funding line on the Prioritized List of Health Services and other services pursuant to OAR 410-141-3820 and 410-141-3830;

(K) Clear and thorough explanation of the specific reasons for the adverse benefit determination;

(L) A reference to the specific statutes and administrative rules to the highest level of specificity for each reason and specific circumstance identified in the ABD notice;

(M) The member's or, if the member provides their written consent as required under OAR 410-141-3890(1), the provider's right to file a written or oral appeal of the MCE's adverse benefit determination with the MCE, including information on exhausting the MCE's one level of appeal, and the procedures to exercise that right;

(N) The member's or the provider's right to request a contested case hearing with the Authority only after the MCE's Appeal Notice of Resolution or where the MCE failed to meet appeal timelines in OAR 410-141-3890 and 410-141-3895, and the procedures to exercise that right;

(O) The circumstances under which an appeal process or contested case hearing can be expedited and how the member or the member's provider may request it;

(P) The member's right to have benefits continue pending resolution of the appeal or contested case hearing, how to request that benefits be continued, and the circumstances under which the member may be required to pay the cost of these services; and

(Q) The member's right to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member's adverse benefit determination including any processes, strategies, or evidentiary standards used by the MCE in setting coverage limits or making the adverse benefit determination.

(b) Use an Authority approved ABD notice form unless the member is a dually eligible member of affiliated Medicare and Medicaid plans, in which case the CMS Integrated Denial Notice may be used as long as it incorporates required information fields in the Oregon's Notice of Adverse Benefit Determination.

(3) The following are notice requirements for Post-service denials:

(a) Meet the content notice requirements specified in 42 CFR § 438.404 and in the MCE contract, including the following information:

(A) MCE contact information and subcontractor contact information, if applicable, included in the ABD notice excluding any cover pages;

(B) Date of the notice;

(C) MCE's name, address, and telephone number;

(D) Name of the member's Primary Care Practitioner (PCP), Primary Care Dentist (PCD), or behavioral health professional if the member has an assigned practitioner or the most specific information available if a member is not assigned to a practitioner due to the clinic/facility model. If the member has not been assigned a practitioner because they enrolled in the MCE within the last 30 days, the NOABD should state PCP, PCD, BH provider assignment has not occurred;

(E) Member's name, D.O.B, address, and OHP member ID number;

(F) Service previously provided and the adverse benefit determination the MCE made;

(G) Date the service was provided;

(H) Name of the provider who provided the service;

(I) Effective date (date claim denied) of the adverse benefit determination if different from the date of the notice;

(J) Diagnosis and procedure codes submitted on the claim including a description in plain language if the MCE is denying the service because of line placement on the Prioritized List of Health Services or the diagnosis and procedure code do not pair on the Prioritized List;

(K) Whether the MCE considered other conditions such as co-morbidity factors if the service was below the funding line on the Prioritized List of Health Services and other services pursuant to OAR 410-141-3820 and 410-141-3830;

(L) Clear and thorough explanation of the specific reasons for the adverse benefit determination;

(M) A reference to the specific statutes and administrative rules to the highest level of specificity for each reason and specific circumstance identified in the ABD notice;

(N) The member's or, if the member provides their written consent as required under OAR 410-141-3890(1), the provider's right to file a written or oral appeal of the MCE's adverse benefit determination with the MCE, including information on exhausting the MCE's one level of appeal, and the procedures to exercise that right;

(O) The member's or the provider's right to request a contested case hearing with the Authority only after the MCE's Appeal Notice of Resolution or where the MCE failed to meet appeal timelines in OAR 410-141-3890 and 410-141-3895, and the procedures to exercise that right;

(P) An explanation to the member that there are circumstances under which an appeal process or contested case hearing can be expedited and how the member or the member's provider may request it but that an expedited appeal and hearing will not be granted for post-service denials as the service has already been provided;

(Q) The member's right to have benefits continue pending resolution of the appeal or contested case hearing, how to request that benefits be continued, and the circumstances under which the member may be required to pay the cost of these services;

(R) The member's right to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member's adverse benefit determination including any processes, strategies, or evidentiary standards used by the MCE in setting coverage limits or making the adverse benefit determination; and

(S) A statement that the provider cannot bill the member for a service rendered unless the member signed an OHP Agreement to Pay form (OHP 3165 or 3166).

(b) Use an Authority approved form unless the member is a dually eligible member of affiliated Medicare and Medicaid plans, in which case the CMS Integrated Denial Notice may be used as long as it incorporates required information fields in the Oregon's Notice of Action/Adverse Benefit Determination.

(4) The MCE shall provide a copy of the form, Request to Review a Health Care Decision Appeal and Hearing Request form (OHP 3302) or approved facsimile, when the MCE issues a Notice of Adverse Benefit Determination.

(5) For requirements of notice of actions/adverse benefit determinations that affect services previously authorized, the MCE shall mail the notice at least 10 days before the date the adverse benefit determination reduction, termination, or suspension takes effect, as referenced in 42 CFR 431.211.

(6) In 42 CFR §§ 431.213 and 431.214, exceptions related to advance notice include the following:

(a) The MCE may mail the notice no later than the date of adverse benefit determination if:

(A) The MCE has factual information confirming the death of the member;

(B) The MCE receives notice that the services requested by the member are no longer desired or the MCE is provided with information that requires termination or reduction in services:

(i) All notices sent to a member under this section shall be in writing, clearly indicate the member understands that the services previously requested will be terminated or reduced as a result of the notice and signed by the member;

(ii) All notices sent by the MCE under this section shall be in writing and shall include a clear statement that advises the member what information was received and that such information required the termination or reduction in the services the member requested.

(C) The MCE can verify that the member has been admitted to an institution where the member is no longer eligible for OHP services from the MCE;

(D) The MCE is unaware of the member's whereabouts and the MCE receives returned mail directed to the member from the post office indicating no forwarding address and the Authority or Department has no other address;

(E) The MCE verifies another state, territory, or commonwealth accepted the member for Medicaid services; or

(F) The member's PCP, PCD, or behavioral health professional prescribed a change in the level of health services.

(b) The MCE must mail the notice five days before the adverse benefit determination when the MCE:

(A) Has facts indicating that an adverse benefit determination should be taken because of probable fraud on part of the member; and

(B) The MCE has verified those facts, whenever possible, through secondary resources.

(c) For denial of payment, the adverse benefit determination shall be mailed at the time of any adverse benefit determination that affects the claim.

(7) Within 60 days from the date on the notice: The member or provider may file an appeal; the member may request a Contested Case Hearing with the Authority after receiving notice that the MCE's adverse benefit determination is upheld; or if the MCE fails to adhere to the notice and timing requirements in 42 CFR 483.408, the Authority may consider the MCE appeals process exhausted.

Notes

Or. Admin. R. 410-141-3885

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

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & 414.727