Or. Admin. R. 410-141-3910 - Grievances and Appeals: Continuation of Benefits
Current through Register Vol. 60, No. 12, December 1, 2021
(1) A member who may be entitled to
continuing benefits may request and receive continuing benefits in the same
manner and same amount while an appeal or contested case hearing is pending:
(a) To be entitled to continuing benefits,
the member shall complete an MCE appeal request or an Authority contested case
hearing request form and check the box requesting continuing benefits by:
(A) The tenth day following the date of the
notice of adverse benefit determination or the notice of appeal resolution;
or
(B) The effective date of the
action proposed in the notice, if applicable.
(b) In determining timeliness, delay for good
cause as defined in OAR 137-003-0528 is not counted;
(c) The MCE must continue the member's
benefits if all of the following occur:
(A)
The appeal involves the termination, suspension, or reduction of previously
authorized services;
(B) The
services were ordered by an authorized provider;
(C) The period covered by the original
authorization has not expired; and
(D) The member timely files for continuation
of benefits.
(d) If, at
the member's request, the MCE continues or reinstates benefits while the appeal
or hearing is pending, the benefits must be continued until one of the
following occurs:
(A) The member fails to
request a hearing and continuation of benefits within 10 calendar days after
the MCE sends the notice of appeal resolution;
(B) The member withdraws the appeal or
request for hearing;
(C) A final
order resolves the hearing.
(e) Member responsibility for services
furnished while the appeal or hearing is pending. If the final resolution of
the appeal or hearing is adverse to the member, that is, upholds the MCE's
adverse benefit determination, the MCE may recover the cost of services
furnished to the member while the appeal and hearing was pending, to the extent
that they were furnished solely because of the requirements of this
section.
(2) For
reversed appeal and hearing resolution services:
(a) Benefits not furnished while the appeal
or hearing is pending. 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;
(b) Benefits
furnished while the appeal or hearing is pending. 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 Authority shall pay for those services in accordance with the
Authority policy and regulations.
Notes
Statutory/Other Authority: ORS 413.032, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.