Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3875 - MCE Grievances And Appeals: Definitions and General Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(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.