OAR 410-120-1580
Provider Appeals — Administrative Review


(1)

An administrative review is a provider appeal process that allows an opportunity for the Administrator of the Division of Medical Assistance Programs (Division) or designee to review a Division decision affecting the provider, provider applicant, Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP) provider, where administrative review is appropriate and consistent with these provider appeal rules OAR 410-120-1560 (Provider Appeals).

(2)

Administrative review is an appeal process under OAR 410-120-1560 (Provider Appeals) that addresses primarily legal or policy issues that may arise in the context of a Division decision that adversely affects the Provider and that is not otherwise reviewed as a claim re-determination, a contested case, or client appeal.

(a)

If the Division finds that the appeal should be handled as a different form of provider appeal or as a client appeal, the Administrator or designee will notify the provider of this determination.

(b)

Within the time limits established by the Division in the administrative review, the provider, provider applicant, CCO or PHP provider must provide Division (and CCO or PHP, if applicable) with a copy of all relevant records, the Division, CCO or PHP decisions, and other materials relevant to the appeal.

(3)

If the Administrator or designee decides that a meeting between the provider, provider applicant, CCO or PHP Provider (and CCO or PHP, if applicable) and the Division staff will assist the review, the Administrator or designee will:

(a)

Notify the provider requesting the review of the date, time, and place the meeting is scheduled;

(b)

Notify the CCO or PHP (when client is enrolled in a CCO or PHP) of the date, time, and place the meeting is scheduled. The CCO or PHP is not required to participate, but is invited to participate in the process.

(4)

The review meeting will be conducted in the following manner:

(a)

It will be conducted by the Division Administrator, or designee;

(b)

No minutes or transcript of the review will be made;

(c)

The provider requesting the review does not have to be represented by counsel during an administrative review meeting and will be given ample opportunity to present relevant information;

(d)

The Division staff will not be available for cross-examination, but the Division staff may attend and participate in the review meeting;

(e)

Failure to appear without good cause constitutes acceptance of the Division’s determination;

(f)

The Administrator may combine similar administrative review proceedings, including the meeting, if the Administrator determines that joint proceedings may facilitate the review;

(g)

The Division Administrator or designee may request the provider, provider Applicant, CCO or PHP Provider making the appeal to submit, in writing, new information that has been presented orally. In such an instance, a specific date for receiving such information will be established.

(5)

The results of the administrative review will be sent to the participants, involved in the review, and to the CCO or PHP when review involved a CCO or PHP provider, in writing, within 30 calendar days of the conclusion of the administrative review proceeding, or such time as may be agreed to by the participants and the Division.

(6)

The Division’s final decision on administrative review is the final decision on appeal and binding on the parties. 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 on administrative review.

Source: Rule 410-120-1580 — Provider Appeals — Administrative Review, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1580.

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
Telehealth
Last Updated

Jun. 8, 2021

Rule 410-120-1580’s source at or​.us