Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0030 - Appeals and Administrative Reviews

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Eligibility, enrollment issues or
			 rescissions. OEBB has an Appeal process consisting of three levels that a
			 member can use if they disagree with an eligibility determination or enrollment
			 record. If the appeal is a result of a rescission, or a determination that the
			 benefit is not a covered benefit, coverage will continue pending the outcome of
			 the appeal. These three levels are:
(a)
			 Appeal. An Appeal is the first level and must be received by OEBB in writing.
			 OEBB staff will respond to all appeals within 30 days of receipt. OEBB staff
			 gathers all information and sets up the Appeal file. OEBB Staff reviews the
			 Appeal and makes a decision. The member is then notified in writing of the OEBB
			 staff's decision. If the decision is an adverse benefit determination, the
			 notice will include the specific reason(s) for the decision, a reference to the
			 specific plan provision or OAR on which the determination was based a
			 description of any additional information required and a description of the
			 OEBB appeals process.
(b) Request
			 for Reconsideration. A Request for Reconsideration is the second level and can
			 be used if the member is not satisfied with the outcome on their Appeal. The
			 request by the member must be received in writing within 31 days of receiving
			 the Appeal decision notification. OEBB staff requests any additional
			 information needed and includes in the Appeal file. The OEBB Management Team
			 reviews all the information contained in the file (from the Appeal and the
			 Request for Reconsideration) and makes a decision. The member is then notified
			 in writing of the OEBB Management Team's decision. If the decision is an
			 adverse benefit determination, the notice will include the specific reason(s)
			 for the decision, a reference to the specific plan provision or OAR on which
			 the determination was based, a description of any additional information
			 required and a description of the OEBB appeals process.
(c) Administrative Review Request. An
			 Administrative Review Request is the third level and can be used if the member
			 is not satisfied with the outcome on their Request for Reconsideration. The
			 request by the member must be in writing OEBB staff requests any additional
			 information and adds it to the Appeal file. OEBB staff will schedule an
			 Administrative Review Committee meeting. OEBB staff will notify the member and
			 all applicable parties of the date, time and location. At the meeting, the
			 Administrative Review Request will be presented to the Administrative Review
			 Committee members and after considering all documentation and possible public
			 comment, a decision is made. The Administrative Review Committee has the
			 authority to grant exceptions to OEBB's Administrative Rules when there are
			 extenuating circumstances which can be supported by documentation and verified
			 by OEBB staff. All such documentation will be included in the member's Appeal
			 file. The member will be notified in writing of the Administrative Review
			 Committee's decision. If the decision is an adverse benefit determination, the
			 notice will include the specific reason(s) for the decision, a reference to the
			 specific plan provision or OAR on which the determination was based a
			 description of any additional information required and a description of the
			 OEBB appeals process.