OAR 410-120-1570: Claim Re-Determinations

(1) If a provider disagrees with an initial claim determination made by the Division of Medical Assistance Program (Division), the provider may request a review for re-determination of the denied claim payment. (2) This rule does not apply to determinations that: (a) Result in a “Notice of Action” that must be provided to the OHP client. If the decision under review requires any notice to the OHP client under applicable rules (OAR 410-120-1860, 410-141-3885), the procedures for notices and hearings must be followed; or (b) Are made by a CCO or PHP regarding services to a CCO or PHP member. The provider must contact the CCO or PHP in accordance with OAR 410-120-1560. (3) How to request a redetermination review: (a) To request a review, the provider must submit a written request to the Division Provider Services Unit within 180 days of the original claim adjudication date; (b) The written request must include all information needed to adjudicate the claim or support changing the original claim determination, including but not limited to: (A) A detailed letter of explanation identifying the specific re-determination denial issue and/or alleged error; (B) All relevant medical records and evidence-based practice data to support the position being asserted on review; (C) The specific service, supply or item being denied, including all relevant codes; (D) Detailed justification for the re-determination of the denied service; and (E) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination; (F) Any information and/or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute. (4) A provider requesting a re-determination review must demonstrate one or more of the following reasons that would allow coverage in the particular case: (a) A below-the-line condition/treatment pair is justified under the co-morbid rule OAR 410-141-3820; (b) A treatment that is part of a covered complex procedure and/or related to an existing funded condition; (c) A service not listed on the HSC Prioritized List that may be covered under OAR 410-141-0480(10); (d) A service that satisfies the Citizenship Waived Medical (CWM) emergency service criteria; (e) Medical documentation of applicable evidence-based practice literature that is consistent with the condition or service under review; (f) A service that satisfies the prudent layperson definition of emergency medical condition; (g) A service intended to prolong survival or palliate symptoms, due to expected length of life consistent with the HSC Statement of Intent for Comfort/Palliative Care; (h) A service that should be covered where denial was due to technical errors and omissions with the Oregon Health Services Commission’s (HSC) Prioritized List of approved Health Services (i) Misapplication of a fee schedule; (j) A denied duplicate claim that the provider believes were incorrectly identified as a duplicate; (k) Incorrect data items, such as provider number, use of a modifier or date of service, unit changes or incorrect charges; (l) Errors with the Medicaid Management Information System (MMIS), such as a code is missing in MMIS that the Oregon Health Services Commission (HSC) has placed on the Prioritized List of Health Services; (m) Services provided without the required prior-authorization, except for those authorizations subject to provision outlined in OAR 410-120-1280(2)(a)(C); (n) A covered diagnostic service. (5) The Division will review all re-determination requests as follows: (a) The review is based on the Division review of supplied documentation and applicable law(s); (b) The Division may request additional information from the provider that it finds relevant to the request under review; (c) The Division does not provide a face-to-face or in person meeting with providers as part of the re-determination review process. (d) The Division will notify a provider requesting review that the re-determination request has been denied if: (A) The provider did not submit a timely request; (B) The required information is not provided at the same time the request is submitted; or (C) The provider fails to submit any additional requested information within 14 business days of request. (6) The Division’s final decision under this rule is the final decision on appeal. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 to 137-004-0092 apply to the Division’s final decision under this rule.