OAR 410-120-1865
Denial, Reduction, or Termination of Services

(1) The purpose of this rule is to describe the requirements governing the denial, reduction, or termination of medical assistance and access to the Authority administrative hearings process for clients requesting or receiving medical assistance services paid for by the Authority on a fee-for-service basis. Grievance, complaint, and appeal procedures for clients receiving services from an MCE shall be governed exclusively by the procedures in OAR 410-0141-3260 and where applicable OAR 410-141-3475.
(2) When the Authority authorizes a course of treatment or covered service, but subsequently acts (as defined in 42 CFR 431.201) to terminate, suspend, or reduce the course of treatment or a covered service, the Authority or its designee shall mail a written notice to the client at least ten days before the date of the termination or reduction of the covered service unless there is documentation that the client had previously agreed to the change as part of the course of treatment or as otherwise provided in 42 CFR 431.213.
(3) The written client notice must inform the client of the action the Authority has taken or intends to take and reasons for the action; a reference to the particular sections of the statutes and rules involved for each reason identified in the notice; the client’s right to request an administrative hearing; an explanation of the circumstances under which benefits may continue pending resolution of the hearing; and how to contact the Authority for additional information. The Authority is not required to grant a hearing if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all recipients.
(4) The Authority shall have the following responsibilities in relation to continuation or reinstatement of benefit under this rule:
(a) If the client requests an administrative hearing before the effective date of the client notice and requests that the services be continued, the Authority shall continue the services. The service shall be continued until whichever of the following occurs first, but may not exceed ninety days from the date of the client’s request for an administrative hearing):
(A) The current authorization expires; or
(B) A decision is rendered about the case that is the subject of the administrative hearing; or
(C) The client is no longer eligible for medical assistance benefits or the health service, supply, or item that is the subject of the administrative hearing is no longer a covered benefit in the client’s medical assistance benefit package; or
(D) The sole issue is one of federal or state law or policy, and the Authority promptly informs the client in writing that services are to be terminated or reduced pending the hearing decision.
(b) The Division shall notify the client in writing that it is continuing the service. The notice shall inform the client that if the hearing is resolved against the client, the cost of any services continued after the effective date of the client notice may be recovered from the client pursuant to 42 CFR 431.230 (Emergency or revolving fund)(b);
(c) The Authority shall reinstate services if:
(A) The Authority takes an action without providing the required notice and the client requests a hearing;
(B) The Authority does not provide the notice in the time required under section (2) of this rule and the client requests a hearing within 10 days of the mailing of the notice of action; or
(C) The post office returns mail directed to the client, but the client’s whereabouts become known during the time the client is still eligible for services;
(D) The reinstated services must be continued until a hearing decision, unless at the hearing it is determined that the sole issue is one of federal or state law or policy.
(d) The Authority shall promptly correct the action taken up to the limit of the original authorization, retroactive to the date the action was taken, if the hearing decision is favorable to the client, or the Authority decides in the client’s favor before the hearing.

Source: Rule 410-120-1865 — Denial, Reduction, or Termination of Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1865.

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 410-120-1865’s source at or​.us