OAR 410-120-1560: Provider Appeals

(1) For purposes of Division provider appeal rules in chapter 410, division 120, the following terms and definitions are used: (a) “Provider” means an individual or entity enrolled with the Division or under contract with the Division that is subject to the Division rules and that has requested an appeal in relation to health care, items, drugs, or services provided or requested to be provided to a client on a fee-for-service basis or under contract with the Division where that contract expressly incorporates these rules; (b) “Provider Applicant” means an individual or entity that has submitted an application to become an enrolled provider with the Division, but the application has not been approved; (c) “Prepaid Health Plan” has the meaning set forth in OAR 410-141-3500, except to the extent that Mental Health Organizations (MHO) have separate procedures applicable to provider grievances and appeals; (d) “Prepaid Health Plan provider” means an individual or entity enrolled with the Division but that provided health care services, supplies or items to a client enrolled with a PHP, including both participating providers and non-participating providers as those terms are defined in OAR 410-141-0000, except that services provided to a client enrolled with an MHO shall be governed by the provider grievance and appeal procedures administered by the Authority’s Addictions and Mental Health Division; (e) The “Provider Appeal Rules” refers to the rules in OAR 410-120-1560 to 410-120-1600, describing the availability of appeal procedures and the procedures applicable to each; (f) “Non-participating provider” has the meaning set forth in OAR 410-141-3500; (g) Coordinated Care Organization (CCO) has the meaning set forth in OAR 410-141-3500. (2) A Division enrolled provider may appeal a Division decision in which the provider is directly adversely affected including but not limited to the following: (a) A denial or limitation of payment allowed for services or items provided; (b) A denial related to an NCCI edit; (c) A denial of provider’s application for new or continued participation in the Medical Assistance Program; or (d) Sanctions imposed, or intended to be imposed, by the Division on a provider or provider entity; and (e) Division overpayment determinations made under OAR 410-120-1397. (3) Client appeals of actions must be handled in accordance with OAR 140-120-1860 and 410-120-1865. (4) A provider appeal is initiated by filing a timely request in writing for review with the Division: (a) A provider appeal request is not required to follow a specific format as long as it provides a clear written expression from a provider or provider applicant expressing disagreement with a Division decision or from a CCO or PHP provider expressing disagreement with a decision by a CCO or PHP. (b) The request must identify the decision made by the Division, a CCO, or PHP that is being appealed and the reason the provider disagrees with that decision. (c) A provider appeal request is timely if it is received by the Division: (A) Within 180 calendar days from the date of the Division’s fee-for-service decision; (B) Within 30 calendar days from the date of the CCO or PHP decision after the provider completes the CCO or PHP appeal process. (5) Types and methods for provider appeals are: (a) Claim redeterminations: A Division denial of or limitation of payment allowed, including prior authorization decision, or Division overpayment determination for services or items provided to a client must be appealed as claim re-determinations under OAR 410-120-1570. (b) Contested Case: A notice of sanctions imposed or intended to be imposed, the effect of the notice of sanction is, or will be, to deny, suspend, or revoke a provider number necessary to participate in the medical assistance on a provider, or provider applicant is entitled to appeal under OAR 410-120-1600. A provider that may appeal a notice of sanction as a contested case may choose to request administrative review instead of contested case hearing if the provider submits a written request for administrative review and agrees in writing to waive the right to a contested case hearing and the Division agrees to review the appeal as an administrative review. (c) Administrative review: All provider appeals of Division decisions not described in section (5)(a) or (b) of this rule are handled as administrative reviews in accordance with OAR 410-120-1580, unless the Division issues an order granting a contested case hearing. (6) Decisions that adversely affect a provider may be made by different program areas within the Authority: (a) Decisions issued by the Office of Payment Accuracy and Recovery (OPAR) or the Authority information security office shall be appealed in accordance with the process described in the notice; (b) Other program areas within the Authority that have responsibility for administering medical assistance funding, such as nursing home care or community mental health and developmental disabilities program services, may make decisions that adversely affect a provider. Those providers are subject to the provider grievance or appeal processes applicable to those payment or program areas; (c) Some decisions that adversely affect a provider are issued on behalf of the Division by Authority contractors such as the Division pharmacy benefits manager, by entities performing statutory functions related to the medical assistance programs such as the Drug Use Review Board, or by other entities in the conduct of program integrity activities applicable to the administration of the medical assistance programs. For these decisions made on behalf of the division in which the Division has legal authority to make the final decision in the matter, a provider may appeal the decision to the Division as an administrative review, and the Division may accept the review; (d) This rule does not apply to contract administration issues that may arise solely between the Division and a CCO or PHP. Those issues shall be governed by the terms of the applicable contract; (e) The Division provides limited provider appeals for CCO or PHP providers or non-participating providers concerning a decision by a CCO or PHP. In general, the relationship between a CCO or PHP and their providers is a contract matter between them. Client appeals are governed by the client appeal rules, not provider appeal rules. (A) The CCO or PHP provider seeking a provider appeal must have a current valid provider enrollment agreement with the Division and, unless the provider is a non-participating provider, must also have a contract with the CCO or PHP; and (B) The CCO or PHP provider or non-participating provider must have exhausted the applicable appeal procedure established by the CCO or PHP, and the request for provider appeal must include a copy of the CCO or PHP written decision that is being appealed and a copy of any CCO or PHP policy being applied in the appeal; and (C) The CCO or PHP provider appeal or non-participating provider appeal from a CCO or PHP decision is limited to issues related to the scope of coverage and authorization of services under the OHP, including whether services are included as covered on the Prioritized List, guidelines, and in the OHP Benefit package. The Division provider appeal process does not include CCO or PHP payment or claims reimbursement amount issues, except in relation to non-participating provider matters governed by Division rule; (D) A timely provider request for appeal must be made within 30 calendar days from the date of the CCO or PHP’s decision and include evidence that the PHP was sent a copy of the provider appeal. In every provider appeal involving a CCO or PHP decision, the CCO or PHP shall be treated as a participant in the appeal. (7) If a provider’s request for appeal is not timely, the Division shall determine whether the failure to file the request was caused by circumstances beyond the control of the provider, provider applicant, or CCO or PHP provider. In determining whether to accept a late request for review, the Division requires the request to be supported by a written statement that explains why the request for review is late. The Division may conduct further inquiry as the Division deems appropriate. In determining timeliness of filing a request for review, the amount of time that the Division determines accounts for circumstances beyond the control of the provider is not counted. The Division may refer an untimely request to the Office of Administrative Hearings for a hearing on the question of timeliness. (8) The burden of presenting evidence to support a provider appeal is on the provider, provider applicant, CCO, or PHP provider: (a) Consistent with OAR 410-120-1360, payment on a claim shall be made only for services that are adequately documented and billed in accordance with OAR 410-120-1280 and all applicable administrative rules related to covered services for the client’s benefit package and establishing the conditions under which services, supplies or items are covered, such as the Prioritized List, medical appropriateness and other applicable standards; (b) Eligibility for enrollment and for continued enrollment is based on compliance with applicable rules, the information submitted or required to be submitted with the application for enrollment and the enrollment agreement, and the documentation required to be produced or maintained in accordance with OAR 410-120-1360. (9) Provider appeal proceedings, if any, shall be held in Salem, unless otherwise stipulated to by all parties and agreed to by the Division.