410-141-3875 MCE Grievances & Appeals: Definitions and General Requirements (1) The following definitions apply for purposes of this rule and OAR 410-141-3835 through OAR 410-141-3915: (a) “Appeal” means a review by an Managed Care Entities (MCE), pursuant to OAR 410-141-3890 of an adverse benefit determination; (b) “Adverse Benefit Determination” means any of the following, consistent with 42 CFR § 438.400(b): (A) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (B) The reduction, suspension, or termination of a previously authorized service; (C) A denial, in whole or in part, of a payment for a service. A payment denied solely because the claim does not meet the definition of a “clean claim” at CFR 447.45(b) is not an adverse benefit determination; (D) The failure to provide services in a timely manner pursuant to OAR 410-141-3515; (E) The MCE’s failure to act within the timeframes provided in these rules regarding the standard resolution of grievances and appeals; (F) For a resident of a rural area with only one MCE, the denial of a member’s request to exercise their legal right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network; or (G) The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities (c) “Clean claim” means one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. For the purpose of this rule, pharmacy claims processed at point-of-sale (POS) that are rejected or denied shall not be considered “clean claims” that may trigger an Notice of Adverse Benefit Determination (NOABD); (d) “Contested Case Hearing” means a hearing before the Authority under the procedures of OAR 410-141-3900 and OAR 410-120-1860; (e) “Continuing benefits” means a continuation of benefits in the same manner and same amount while an appeal or contested case hearing is pending, pursuant to OAR 410-141-3910; (f) “Grievance” means a member's expression of dissatisfaction to the MCE or to the Authority about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights regardless of whether remedial action is requested. A Grievance also includes a member’s right to dispute an extension of time proposed by the MCE to make an authorization decision; (g) “Member” for actions taken regarding grievances and appeals, “member” includes, as appropriate, the member, the member’s representative, and the representative of a deceased member’s estate. With respect to MCE notification requirements, a separate notice must be sent to each individual who falls within this definition; (h) “Notice of Adverse Benefit Determination” means the notice must meet all requirements found at 42 CFR 438.400. (2) MCEs shall establish and have an Authority approved process and written procedures for compliance with grievance and appeals requirements that shall include the following: (a) Member rights to file a grievance at any time for any matter other than an adverse benefit determination; (b) Member rights to appeal and request an MCE review of a notice of adverse benefit determination, including the ability of providers and authorized representatives to appeal on behalf of a member; (c) Member rights to request a contested case hearing regarding an MCE notice of adverse benefit determination once the plan has issued a written notice of appeal resolution under the Administrative Procedures Act; (d) An explanation of how MCEs shall accept, acknowledge receipt, process, and respond to grievances, appeals, and contested case hearing requests within the required timeframes; (e) Compliance with grievance and appeals requirements as part of state quality strategy and to enforce a consistent response to complaints of violations of consumer rights and protections; (A) Provide the member a reasonable opportunity to present evidence and testimony and make legal and factual arguments in person as well as in writing; (B) The MCE shall inform the member of the limited time available for this sufficiently in advance of the resolution timeframe for both standard and expedited appeals; (C) The MCE shall provide the member the member’s case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCE (or at the direction of the MCE) in connection with the appeal of the adverse benefit determination at no charge and sufficiently in advance of the standard resolution timeframe for appeals; and (D) Ensure documentation of appeals in an appeals log maintained by the MCE that complies with OAR 410-141-3915 and is consistent with contractual requirements. (3) The MCE shall provide information to members regarding the following: (a) An explanation of how MCEs shall accept, process, and respond to grievances, appeals, and contested case hearing requests, including requests for expedited review of grievances and appeals; (b) Member rights and responsibilities; and (c) How to file for a hearing through the state’s eligibility hearings unit related to the member’s current eligibility with OHP. (4) The MCE shall adopt and maintain compliance with grievances and appeals process timelines in 42 CFR §§ 438.408 (a) and these rules. (5) Upon receipt of a grievance or appeal, the MCE shall: (a) Within (5) five business days, resolve or acknowledge receipt of the grievance or appeal to the member and the member’s provider where indicated; (b) Give the grievance or appeal to staff with the authority to act upon the matter; (c) Consistent with confidentiality requirements, obtain documentation of all relevant facts concerning the issues, including taking into account all comments, documents, records, and other information submitted by the member without regard to whether the information was submitted or considered in the initial adverse benefit determination or resolution of grievance; (d) Ensure staff and any consulting experts making decisions on grievances and appeals are: (A) Not involved in any previous level of review or decision making nor a subordinate of any such individual; (B) Health care professionals with appropriate clinical expertise in treating the member’s condition or disease, if the grievance or appeal involves clinical issues or if the member requests an expedited review. Health care professionals shall make decisions for the following: (i) An appeal of a denial that is based on lack of medically appropriate services or involves clinical issues; (ii) A grievance regarding denial of expedited resolution of an appeal or involves clinical issues. (C) Taking into account all comments, documents, records, and other information submitted by the member without regard to whether the information was submitted or considered in the initial adverse benefit determination; (D) Not receiving incentivized compensation for utilization management activities by ensuring that individuals or entities who conduct utilization management activities are not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. (6) The MCE shall analyze all grievances, appeals, and hearings in the context of quality improvement activity pursuant to OAR 410-141-3525 and 410-141-3875. (7) MCEs shall keep all health care information concerning a member's request confidential, consistent with appropriate use or disclosure as defined in 45 CFR 164.501 and include providing member assurance of confidentiality in all written, oral, and posted material in grievance and appeal processes. (8) The following pertains to the release of a member’s information: (a) The MCE and any provider whose authorizations, treatments, services, items, quality of care, or requests for payment are involved in the grievance, appeal, or hearing may use this information without the member’s signed release for purposes of: (A) Resolving the matter; or (B) Maintaining the grievance or appeals log as specified in 42 CFR 438.416. (b) If the MCE needs to communicate with other individuals or entities not listed in subsection (a) to respond to the matter, the MCE shall obtain the member’s signed release and retain the release in the member’s record. (9) The MCE shall provide Members with any reasonable assistance in completing forms and taking other procedural steps related to filing grievances, appeals, or hearing requests. Reasonable assistance includes but is not limited to: (a) Assistance from certified community health workers, peer wellness specialists, or personal health navigators to participate in processes affecting the member’s care and services; (b) Free interpreter services or other services to meet language access requirements where required in 42 CFR §438.10; (c) Providing auxiliary aids and services upon request including but not limited to toll-free phone numbers that have adequate TTY/TTD and interpreter capabilities; and (d) Reasonable accommodation or policy and procedure modifications as required by any disability of the member. (10) The MCE, its subcontractors, and its participating providers may not: (a) Discourage a member from using any aspect of the grievance, appeal, or hearing process or take punitive action against a provider who requests an expedited resolution or supports a member’s appeal; (b) Encourage the withdrawal of a grievance, appeal, or hearing request already filed; or (c) Use the filing or resolution of a grievance, appeal, or hearing request as a reason to retaliate against a member or to request member disenrollment. (11) In all MCE administrative offices and in those physical, behavioral, and dental health offices where the MCE has delegated responsibilities for appeal, hearing request, or grievance involvement, the MCE shall have the following forms available: (a) OHP Complaint Form (OHP 3001); (b) MCE appeal forms (OHP 3302; or approved facsimile); (c) Hearing request form Request to Review a Health Care Decision (OHP 3302). (12) In all investigations or requests from the Department of Human Services Governor’s Advocacy Office, the Authority’s Ombudsperson or hearing representatives, the MCE, and participating providers shall cooperate in ensuring access to all activities related to member appeals, hearing requests, and grievances including providing all requested written materials in required timeframes. (13) The member may request continuation of benefits from their MCE for services that were discontinued. If the member qualifies for continuation of benefits the MCE must provide the services while the appeal or administrative hearing is pending pursuant to OAR 410-141-3910. (14) Adjudication of appeals in a member grievance and appeals process may not be delegated to a subcontractor. If the MCE delegates any other portion of the grievance and appeal process to a subcontractor, the MCE must, in addition to the general obligations established under OAR 410-141-3505, do the following: (a) Ensure the subcontractor meets the requirements consistent with this rule and OAR 410-141-3715 through 410-141-3915; (b) Monitor the subcontractor’s performance on an ongoing basis; (c) Perform a formal compliance review at least once a year to assess performance, deficiencies, or areas for improvement; and (d) Ensure the subcontractor takes corrective action for any identified areas of deficiencies that need improvement. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 & 414.727 History: DMAP 98-2023, amend filed 12/28/2023, effective 01/01/2024 DMAP 89-2022, amend filed 12/16/2022, effective 01/01/2023 DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021 DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020