OAR 409-023-0125: Requirements for a Process for Patient Appeals of Financial Assistance Determinations

(1) Requirements for patient appeals of financial assistance determination are effective January 1, 2025. (2) Hospitals must document their financial assistance appeals process in their financial assistance policy. (3) A patient may only appeal determinations based on applications for financial assistance. (4) If a hospital denies an application for financial assistance, finds the application to be incomplete or missing documentation, or provides a patient cost adjustment for less than 100% of the patient costs, the hospital must, within ten (10) business days, notify the patient of their ability to take corrective action or appeal the determination. The notification must meet the following criteria: (a) The notification must be written in plain language and either the preferred language of the patient or otherwise in alignment with the translation standards specified in ORS 442.614. (b) The notification may be delivered by mail, email, in person, or through an online portal, if the patient is a registered user of the hospital’s portal. The notification must be delivered separately and in addition to any financial assistance statements included on billing statements. (c) The notification must clearly specify whether the application was incomplete or if the patient was denied due to not meeting eligibility criteria. (A) If the application is found to be incomplete, missing documentation, or containing errors, the notification must designate the application as incomplete and requiring further action by the patient. The notice must further clearly describe the deficiencies and the actions the patient can take to complete the application by correcting the deficiencies. (B) If the application was denied based on a failure to meet eligibility criteria, the notification must specify the relevant eligibility criteria and provide contact information so that the patient can request further information about the relevant eligibility criteria and the information that was used by the hospital to reach its determination. (d) The notification must include a clear description of how the patient may submit corrections or additional documentation and how the patient may request an appeal. At a minimum, a patient must be able to submit corrections or additional documentations and request an appeal electronically, by either email or through a secure online portal, by mail, and by in-person delivery. (e) The notification must inform the patient that if the patient chooses to appeal, the patient may request review by the hospital’s Chief Financial Officer or a designee of the hospital’s Chief Financial Officer who has been delegated decision-making authority over the appeal. (f) The notification must inform the patient that the patient may also submit an appeal through a written statement or other supporting documentation. (g) The notification must provide contact information to an appropriate hospital representative who may answer questions about the appeals process or the patient’s financial assistance application. (5) A hospital must allow a patient the remaining duration of the 240-day application period after the date of the first post-discharge billing statement for the care provided, as specified in 26 CFR 1.501(r)-1(b)(3), or 45 days from the date the patient was notified of the financial assistance determination to correct deficiencies in the application or request an appeal, whichever is greater. A hospital may conduct standard billing practices during the application period if there is not a pending appeal. However, this does not remove the hospital’s obligation to reimburse a patient if found to be eligible for financial assistance, in accordance with ORS 442.615. (6) During the pendency of an appeal a hospital must: (a) Suspend all collection activities if the hospital has initiated collection activities; and (b) If the hospital has sold the debt under appeal to a collection agency or has authorized a collection agency to collect debts on behalf of the hospital, the hospital must notify the collection agency to suspend collection activities; and (c) Provide the patient with a written statement, delivered in accordance with OAR 409-023-0125(4)(b), and any request by the patient to use a specific, permitted, different delivery method, that contains: (A) Confirmation of receipt of the patient’s appeal request; (B) Notice that: (i) The hospital has suspended all collection activities that it has initiated; and (ii) If the hospital has sold debt to a collection agency or authorized a collection agency to collect debts on behalf of the hospital, that the hospital has notified the collection agency to suspend collection activities. (C) Information on any actions the patient may take if a patient has requested a review by the hospital’s Chief Financial Officer or a designee. (7) If it is determined by the hospital officer with the authority to determine the appeal that the patient must provide additional information, the patient must be allowed an additional 45 days, minimum, to provide the requested information. This additional time period runs from the date the hospital officer with the authority to determine the appeal informs the patient that they must supply additional information. (8) A hospital may allow for multiple meetings to make a decision about the appeal. (9) A hospital must allow for a third party acting with consent and on behalf of the patient to take action on a patient’s application and/or represent the patient on appeal. A hospital may require documentation of consent to representation from the patient. (10) A hospital must issue a written determination on the appeal within 30 days of either the date of the final appeals meeting or the date of receipt of corrections related to application deficiencies, whichever is later. The hospital must communicate its determination in accordance with plain language and preferred language requirements established in OAR 409-023-0125(4)(a) and it must be delivered in accordance with OAR 409-023-0125(4)(b), and any request by the patient to use a specific, permitted, delivery method. (a) If the final determination results in a denial of financial assistance, the hospital must also notify the patient of the date on which suspended collection activities, if any, will resume. (b) A hospital may not resume suspended collection activities until a patient is notified of the final determination. (11) A patient who has taken corrective action on an application that was determined to have deficiencies may request an appeal if the application is subsequently denied based on a failure to meet the hospital’s eligibility criteria.