OAR 410-141-3890: Grievances & Appeals: Appeal Process

(1) A member, member representative, or provider with the member’s written consent, may file an oral or written appeal with the Managed Care Entity (MCE) to: (a) Express disagreement with an adverse benefit determination; or (b) Oral appeals timeframes shall begin when there is established contact made between the member and an MCE representative. If the member leaves a voice mail message with the MCE indicating that they wish to appeal a denial the MCE shall make reasonable efforts (multiple calls at different times of day) to reach the member by phone to get the details of the service they wish to appeal. The MCE shall document each attempt to reach the member (date(s) and time(s)) by phone and make note of the date they establish contact with the member and are able to attain the appeal information needed to process the appeal. (2) Each MCE may have only one level of appeal for members, and members shall complete the appeals process with the MCE prior to requesting a contested case hearing. (3) For standard resolution of an appeal and notice to the affected parties, the MCE shall establish a timeframe that is no longer than 16 days from the day the MCE receives the appeal: (a) If an MCE fails to adhere to the notice and timing requirements in 42 CFR § 438.408, the member is considered to have exhausted the MCE’s appeals process. In this case, the member may initiate a contested case hearing; (b) The MCE may extend the timeframes from section (3) of this rule by up to 14 days if: (A) The member requests the extension; or (B) The MCE shows to the satisfaction of the Authority upon its request that there is need for additional information and how the delay is in the member's interest. (c) If the MCE extends the timeframes but not at the request of the member, the MCE shall: (A) Make reasonable efforts (including as necessary multiple calls at different times of day) to give the member prompt oral notice of the delay; (B) Within two (2) days, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if the member disagrees with that decision; (C) Resolve the appeal as expeditiously as the member's health condition requires and no later than the date the extension expires. (4) For expedited resolution of an appeal please see OAR 410-141-3895. A request for an expedited appeal for a service that has already been provided to the member (post-service) shall not be granted. The MCE shall transfer the appeal to the timeframe for standard resolution as set forth above section (3) of this rule. (5) For purposes of this rule, an appeal includes a request from the Authority to the MCE for review of a notice. (6) A member or the provider on the member’s behalf may request an appeal either orally or in writing directly to the MCE for any notice or failure to act within the timeframes provided in 42 CFR §438.408 (a) regarding the standard resolution of appeals by the MCE: (a) The MCE shall ensure oral requests for appeal of a notice are treated as appeals to establish the earliest possible filing date; (b) The member shall file the appeal with the MCE no later than 60 days from the date on the notice. (7) Parties to the appeal include, as applicable: (a) The member and their representative; or (b) The legal representative of a deceased Member’s estate. (8) The MCE shall resolve each standard appeal in time period defined above in section (4) of this rule. The MCE shall provide the member with a notice of appeal resolution as expeditiously as the member’s health condition requires, or within 72 hours for matters that meet the requirements for expedited appeals in OAR 410-141-3895. (9) 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. The MCE must take the following steps: (a) Notify the Member, the member’s representative (if applicable) both orally and in writing and the member’s provider in writing of the available services and how to access them; (b) Enter the prior authorization into the system or adjust the encounter data claim representing the service. (10) 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 State shall pay for those services in accordance with the Authority policy and regulations. (11) The written notice of appeal resolution shall be in a format approved by the Authority. The notice shall contain, as appropriate, the same elements as the notice of adverse benefit determination, as specified in OAR 410-141-3885, in addition to: (a) The date the member filed the appeal with the MCE; (b) The results of the resolution process and the date the MCE completed the resolution; (c) Effective date of the appeal decision; (d) For appeals resolved partially or wholly in favor of the member, an explanation that the member may now access those benefits that were denied and how to do so; and (e) For appeals not resolved wholly in favor of the member: (A) Reasons for the resolution and a reference to the particular sections of the statutes and rules involved for each reason identified in the Notice of Appeal Resolution relied upon to deny the appeal; (B) The right to request a contested hearing or expedited hearing with the Authority and how to do so; (C) The right to request to continue receiving benefits while the hearing is pending and how to do so; and (D) An explanation that the member may be held liable for the cost of those benefits if the hearing decision upholds the MCE’s adverse benefit determination; (E) Copies of the appropriate forms: Request to Review a Health Care Decision Appeal and Hearing Request form (OHP 3302) or approved facsimile.