OAR 436-015-0110: Dispute Resolution

(1) Disputes which arise between any party and an MCO must first be processed through the dispute resolution process of the MCO. (2) The MCO must promptly provide a written summary of the MCO’s dispute resolution process to anyone who requests it, or to any party or their representative disputing any action of the MCO or affected by a dispute. The written summary must include at least the following: (a) The title, address, and telephone number of the contact person at the MCO who is responsible for the dispute resolution process; (b) The types of issues the MCO will consider in its dispute resolution process; (c) A description of the procedures and time frames for submission, processing, and decision at each level of the dispute resolution process including the right of an aggrieved party to request administrative review by the director if the party disagrees with the final decision of the MCO; and (d) A statement that absent a showing of good cause, failure to timely appeal to the MCO shall preclude appeal to the director. (3) The MCO must notify the worker and the worker’s attorney when the MCO: (a) Receives any complaint or dispute under this rule; or (b) Issues any decision under this rule. (4) Whenever an MCO denies a service, or a party otherwise disputes a decision of the MCO, the MCO must send written notice of its decision to all parties that can appeal the decision. If the MCO provides a dispute resolution process for the issue, the notice must include the following in bold text and formatted as follows: Notice to the worker and all other parties: If you want to appeal this decision, you must: - Notify us in writing within 30 days of the mailing date of this notice - Send your written request for review to: {MCO name} {MCO address} If you have questions, contact {MCO contact person and phone number}. If you do not notify us in writing within 30 days, you will lose all rights to appeal the decision, unless you show good cause. If you appeal within the 30-day timeframe, we will review the disputed decision and notify you of our final decision within 60 days of your request. After that, if you still disagree with our decision, you may appeal to the Department of Consumer and Business Services (DCBS) for further review. If you do not seek dispute resolution through us, you will lose your right to appeal to DCBS. (5) If an MCO receives a complaint or dispute that is not included in the MCO dispute resolution process, the MCO must, within seven days from the date of receiving the complaint, notify the parties in writing of their right to request review by the director under OAR 436-015-0008. The notice must include the following in bold text and formatted as follows: Notice to the worker and all other parties: {MCO name} does not have a process to review the type of issue you have raised. To pursue this issue you must request administrative review by the Department of Consumer and Business Services (DCBS) within 60 days of the mailing date of this notice. If you do not notify DCBS in writing within 60 days, you will lose all rights to appeal the decision. Send your written request for review to: DCBS Workers’ Compensation Division Medical Resolution Team 350 Winter Street NE PO Box 14480 Salem OR 97309-0405 For help, call the Workers’ Compensation Division’s toll-free hotline at 800-452-0288 and ask to speak with a benefit consultant. (6) The time frame for resolution of the dispute by the MCO may not exceed 60 days from the date the MCO receives the dispute to the date it issues its final decision. After the MCO resolves a dispute under ORS 656.260(15), the MCO must notify all parties to the dispute in writing with an explanation of the reasons for the decision. If the worker’s attorney has notified the insurer in writing of representation, the MCO must also send a copy of the explanation of the reasons for the decision to the attorney. This notice must inform the parties of the next step in the process, including the right of an aggrieved party to request administrative review by the director under OAR 436-015-0008. The notice must include the following in bold text and formatted as follows: Notice to the worker and all other parties: If you want to appeal this decision, you must do so within 60 days from the mailing date of this notice. If you do not notify the Department of Consumer and Business Services (DCBS) in writing within 60 days, you will lose all rights to appeal the decision. Send your written request for review to: DCBS Workers’ Compensation Division Medical Resolution Team 350 Winter Street NE PO Box 14480 Salem OR 97309-0405 For help, call the Workers’ Compensation Division’s toll-free hotline at 800-452-0288 and ask to speak with a benefit consultant. (7) If the MCO fails to issue a decision within 60 days, the MCO’s initial decision is automatically deemed affirmed. The parties may immediately proceed as though the MCO had issued an order affirming the MCO decision. The MCO must notify the parties of the next step in the process, including the right of an aggrieved party to request administrative review by the director under OAR 436-015-0008 including the appeal rights provided in (6) of this rule. (8) The director may assist in resolution of a dispute before the MCO. The director may issue an order to further the dispute resolution process. Any of the parties also may request in writing that the director assist in resolution if the dispute cannot be resolved by the MCO.