OAR 410-120-1570
Claim Re-Determinations

(1)

If a provider disagrees with an initial claim determination made by the Division of Medical Assistance Program (Division), the provider may request a review for re-determination of the denied claim payment.

(2)

This rule does not apply to determinations that:

(a)

Result in a “Notice of Action” that must be provided to the OHP client. If the decision under review requires any notice to the OHP client under applicable rules (OAR 410-120-1860 (Contested Case Hearing Procedures), 410-414-0263), the procedures for notices and hearings must be followed; or

(b)

Are made by a CCO or PHP regarding services to a CCO or PHP member. The provider must contact the CCO or PHP in accordance with 410-120-1560 (Provider Appeals).

(3)

How to request a redetermination review:

(a)

To request a review, the provider must submit a written request to the Division Provider Services Unit within 180 days of the original claim adjudication date.

(b)

The written request must include all information needed to adjudicate the claim or support changing the original claim determination, including but not limited to:

(A)

A detailed letter of explanation identifying the specific re-determination denial issue and/or alleged error;

(B)

All relevant medical records and evidence-based practice data to support the position being asserted on review;

(C)

The specific service, supply or item being denied, including all relevant codes;

(D)

Detailed justification for the re-determination of the denied service; and

(E)

A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination;

(F)

Any information and/or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute.

(4)

A provider requesting a re-determination review must demonstrate one or more of the following reasons that would allow coverage in the particular case:

(a)

A below-the-line condition/treatment pair is justified under the co-morbid rule OAR 410-141-0480(8);

(b)

A treatment that is part of a covered complex procedure and/or related to an existing funded condition;

(c)

A service not listed on the HSC Prioritized List that may be covered under OAR 410-141-0480(10);

(d)

A service that satisfies the Citizen/Alien-Waived Emergency Medical (CAWEM) emergency service criteria;

(e)

Medical documentation of applicable evidence-based practice literature that is consistent with the condition or service under review;

(f)

A service that satisfies the prudent layperson definition of emergency medical condition;

(g)

A service intended to prolong survival or palliate symptoms, due to expected length of life consistent with the HSC Statement of Intent for Comfort/Palliative Care;

(h)

A service that should be covered where denial was due to technical errors and omissions with the Oregon Health Services Commission’s (HSC) Prioritized List of approved Health Services

(i)

Misapplication of a fee schedule;

(j)

A denied duplicate claim that the provider believes were incorrectly identified as a duplicate;

(k)

Incorrect data items, such as provider number, use of a modifier or date of service, unit changes or incorrect charges;

(l)

Errors with the Medicaid Management Information System (MMIS), such as a code is missing in MMIS that the Oregon Health Services Commission (HSC) has placed on the Prioritized List of Health Services;

(m)

Services provided without the required prior-authorization, except for those authorizations subject to provision outlined in OAR 410-120-1280 (Billing)(2)(a)(C);

(n)

A covered diagnostic service.

(5)

The Division will review all re-determination requests as follows:

(a)

The review is based on the Division review of supplied documentation and applicable law(s);

(b)

The Division may request additional information from the provider that it finds relevant to the request under review;

(c)

The Division does not provide a face-to-face meeting with providers as part of the re-determination review process.

(d)

The Division will notify a provider requesting review that the re-determination request has been denied if:

(A)

The provider did not submit a timely request;

(B)

The required information is not provided at the same time the request is submitted; and/or

(C)

The provider fails to submit any additional requested information within 14 business days of request.

(7)

The Division’s final decision under this rule is the final decision on appeal. Under ORS 183.484 (Jurisdiction for review of orders other than contested cases), this decision is an order in other than a contested case. ORS 183.484 (Jurisdiction for review of orders other than contested cases) and the procedures in OAR 137-004-0080 (Reconsideration — Orders in Other than Contested Case) to 137-004-0092 (Stay Proceeding and Order — Orders in Other than Contested Case) apply to the Division’s final decision under this rule.

Source: Rule 410-120-1570 — Claim Re-Determinations, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1570.

410‑120‑0000
Acronyms and Definitions 410‑120‑0003
OHP Standard Benefit Package 410‑120‑0006
Medical Eligibility Standards 410‑120‑0011
Effect of COVID-19 Emergency Authorities on Administrative Rules 410‑120‑0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence 410‑120‑0030
Children’s Health Insurance Program 410‑120‑0035
Public Entity 410‑120‑0045
Applications for Medical Assistance at Provider locations 410‑120‑0250
Managed Care Entity 410‑120‑1140
Verification of Eligibility and Coverage 410‑120‑1160
Medical Assistance Benefits and Provider Rules 410‑120‑1180
Medical Assistance Benefits: Out-of-State Services 410‑120‑1190
Medically Needy Benefit Program 410‑120‑1195
SB 5548 Population 410‑120‑1200
Excluded Services and Limitations 410‑120‑1210
Medical Assistance Benefit Packages and Delivery System 410‑120‑1260
Provider Enrollment 410‑120‑1280
Billing 410‑120‑1285
Recoupment and Data Sharing with Third-Party Insurers 410‑120‑1295
Non-Participating Provider 410‑120‑1300
Timely Submission of Claims 410‑120‑1320
Authorization of Payment 410‑120‑1340
Payment 410‑120‑1350
Buying-Up 410‑120‑1360
Requirements for Financial, Clinical and Other Records 410‑120‑1380
Compliance with Federal and State Statutes 410‑120‑1385
Compliance with Public Meetings Law 410‑120‑1390
Premium Sponsorships 410‑120‑1395
Program Integrity 410‑120‑1396
Provider and Contractor Audits 410‑120‑1397
Recovery of Overpayments to Providers — Recoupments and Refunds 410‑120‑1400
Provider Sanctions 410‑120‑1460
Type and Conditions of Sanction 410‑120‑1510
Fraud and Abuse 410‑120‑1560
Provider Appeals 410‑120‑1570
Claim Re-Determinations 410‑120‑1580
Provider Appeals — Administrative Review 410‑120‑1600
Provider Appeals — Contested Case Hearings 410‑120‑1855
Client’s Rights and Responsibilities 410‑120‑1860
Contested Case Hearing Procedures 410‑120‑1865
Denial, Reduction, or Termination of Services 410‑120‑1870
Client Premium Payments 410‑120‑1875
Agency Hearing Representatives 410‑120‑1880
Contracted Services 410‑120‑1920
Institutional Reimbursement Changes 410‑120‑1940
Interest Payments on Overdue Claims 410‑120‑1960
Payment of Private Insurance Premiums 410‑120‑1980
Requests for Information and Public Records 410‑120‑1990
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Last Updated

Jun. 8, 2021

Rule 410-120-1570’s source at or​.us