OAR 410-141-3885
Grievances & Appeals: Notice of Action/Adverse Benefit Determination

(1) When an MCE has made an adverse benefit determination, the MCE shall notify the requesting provider and give the member and the member’s representative a written notice of action/adverse benefit determination notice. The notice shall:
(a) Comply with the Authority’s formatting and readability standards in OAR 410-141-3585 (MCE Member Relations: Education and Information) and 42 CFR § 438.10 and be written in language sufficiently clear that a layperson could understand the notice and make an informed decision about appealing and following the process for requesting an appeal;
(b) For timing of notices, follow timelines required for the specific service authorization or type via oral and written mechanisms for any service request of the member or the member’s provider outlined in OAR 410-141-3835 (MCE Service Authorization) MCE Service Authorization or otherwise specified in this rule;
(c) Meet the content notice requirements specified in 42 CFR § 438.404 and in the MCE contract, including the following information:
(A) Date of the notice;
(B) MCE’s name, address, and telephone number;
(C) Name of the member’s Primary Care Practitioner (PCP), Primary Care Dentist (PCD), or behavioral health professional, as applicable;
(D) Member’s name, address, and member ID number;
(E) Service requested or previously provided and the adverse benefit determination the MCE made or intends to make, including whether the MCE is denying, terminating, suspending, or reducing a service or denial of payment;
(F) Date of the service or date service was requested by the provider or member;
(G) Name of the provider who performed or requested the service;
(H) Effective date of the adverse benefit determination if different from the date of the notice;
(I) Whether the MCE considered other conditions such as co-morbidity factors if the service was below the funding line on the Prioritized List of Health Services and other services pursuant to 410-141-3820 (Covered Services) and 410-141-3830 (Prioritized List of Health Services);
(J) Clear and thorough explanation of the specific reasons for the adverse benefit determination;
(K) A reference to the specific statutes and administrative rules to the highest level of specificity for each reason and specific circumstance identified in the ABD notice;
(L) The member’s or, if the member provides their written consent as required under OAR 410-141-3890 (Grievances & Appeals: Appeal Process)(1), the provider’s right to file an appeal of the MCE’s adverse benefit determination with the MCE, including information on exhausting the MCE’s one level of appeal, and the procedures to exercise that right;
(M) The member’s or the provider’s right to request a contested case hearing with the Authority only after the MCE’s Appeal Notice of Resolution or where the MCE failed to meet appeal timelines in OAR 410-141-3890 (Grievances & Appeals: Appeal Process) and 410-141-3895 (Grievances & Appeals: Expedited Appeal), and the procedures to exercise that right;
(N) The circumstances under which an appeal process or contested case hearing can be expedited and how the member or the member’s provider may request it;
(O) The member’s right to have benefits continue pending resolution of the appeal or contested case hearing, how to request that benefits be continued, and the circumstances under which the member may be required to pay the cost of these services; and
(P) The member’s right to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member’s adverse benefit determination including any processes, strategies, or evidentiary standards used by the MCE in setting coverage limits or making the adverse benefit determination.
(d) Use an Authority approved form unless the member is a dually eligible member of affiliated Medicare and Medicaid plans, in which case the CMS Integrated Denial Notice may be used as long as it incorporates required information fields in the Oregon’s Notice of Action/Adverse Benefit Determination.
(2) The MCE shall provide copies of the following forms when the MCE issues a Notice of Adverse Benefit Determination:
(a) Hearing request form (MSC 443) and Notice of Hearing Rights (OHP 3030); or
(b) The Health Systems Division Service Denial Appeal and Hearing Request form (OHP 3302) or approved facsimile.
(3) For requirements of notice of actions/adverse benefit determinations that affect services previously authorized, the MCE shall mail the notice at least 10 days before the date the adverse benefit determination reduction, termination, or suspension takes effect, as referenced in 42 CFR 431.211.
(4) In 42 CFR §§ 431.213 and 431.214, exceptions related to advance notice include the following:
(a) The MCE may mail the notice no later than the date of adverse benefit determination if:
(A) The MCE has factual information confirming the death of the member;
(B) The MCE receives notice that the services requested by the member are no longer desired or the MCE is provided with information that requires termination or reduction in services:
(i) All notices sent by a member under this section shall be in writing, clearly indicate the member understands that the services previously requested will be terminated or reduced as a result of the notice and signed by the member;
(ii) All notices sent by the MCE under this section shall be in writing and shall include a clear statement that advises the member what information was received and that such information required the termination or reduction in the services the member requested.
(C) The MCE can verify that the member has been admitted to an institution where the member is no longer eligible for OHP services from the MCE;
(D) The MCE is unaware of the member’s whereabouts and the MCE receives returned mail directed to the member from the post office indicating no forwarding address and the Authority or Department has no other address;
(E) The MCE verifies another state, territory, or commonwealth accepted the member for Medicaid services; or
(F) The member’s PCP, PCD, or behavioral health professional prescribed a change in the level of health services.
(b) The MCE must mail the notice five days before the adverse benefit determination when the MCE:
(A) Has facts indicating that an adverse benefit determination should be taken because of probable fraud on part of the member; and
(B) The MCE has verified those facts, whenever possible, through secondary resources.
(c) For denial of payment, the adverse benefit determination shall be mailed at the time of any adverse benefit determination that affects the claim.
(5) Within 60 days from the date on the notice: The member or provider may file an appeal; the member may request a Contested Case Hearing with the Authority after receiving notice that the MCE’s adverse benefit determination is upheld; or if the MCE fails to adhere to the notice and timing requirements in 42 CFR 483.408, the Authority may consider the MCE appeals process exhausted.

Source: Rule 410-141-3885 — Grievances & Appeals: Notice of Action/Adverse Benefit Determination, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3885.

410–141–3500
Definitions 410–141–3501
Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation 410–141–3505
Use of Subcontractors 410–141–3510
Provider Contracting and Credentialing 410–141–3515
Network Adequacy 410–141–3520
Record Keeping and Use of Health Information Technology 410–141–3525
Outcome and Quality Measures 410–141–3530
Sanctions 410–141–3540
Member Protections 410–141–3545
Coordinated Care Organization Behavioral Health Provider, Treatment and Facility Certification and Licensure 410–141–3550
Resolving Disputes between MCEs and the Authority 410–141–3555
Resolving Disputes between Health Care Entities and CCOs that Concern CCO Contact Award 410–141–3560
Resolving Contract Disputes Between Health Care Entities and CCOs 410–141–3565
Managed Care Entity Billing 410–141–3566
Telehealth Service and Reimbursement Requirements 410–141–3570
Managed Care Entity Encounter Claims Data Reporting 410–141–3575
MCE Member Relations: Marketing 410–141–3580
MCE Member Relations: Potential Member Information 410–141–3585
MCE Member Relations: Education and Information 410–141–3590
MCE Member Relations: Member Rights and Responsibilities 410–141–3600
MCE Assessment: Definitions 410–141–3601
MCE Assessment: General Administration 410–141–3605
MCE Assessment: Disclosure of Information 410–141–3610
MCE Assessment: Calculation, Report, Due Date, Verification 410–141–3615
MCE Assessment: Filing an Amended Report 410–141–3620
MCE Assessment: Determining the Date Filed 410–141–3625
MCE Assessment: Authority to Audit Records 410–141–3630
MCE Assessment: Determining Assessment Liability on Failure to File 410–141–3635
MCE Assessment: Financial Penalty for Failure to File a Report or Failure to Pay Assessment When Due 410–141–3640
MCE Assessment: Notice of Proposed Action 410–141–3645
MCE Assessment: Hearing Process 410–141–3650
MCE Assessment: Final Order of Payment 410–141–3655
Assessment: Remedies Available after Final Order of Payment 410–141–3700
CCO Application and Contracting Procedures 410–141–3705
Criteria for CCOs 410–141–3710
Contract Termination and Close-Out Requirements 410–141–3715
CCO Governance 410–141–3720
Service Area Change for Existing CCOs 410–141–3725
CCO Contract Renewal Notification 410–141–3730
Community Health Assessment and Community Health Improvement Plans 410–141–3735
Social Determinants of Health and Equity 410–141–3740
Traditional Health Workers 410–141–3800
CCO Enrollment for Children Receiving Health Services 410–141–3805
Mandatory MCE Enrollment Exceptions 410–141–3810
Disenrollment from MCEs 410–141–3815
CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services 410–141–3820
Covered Services 410–141–3825
Excluded Services and Limitations 410–141–3830
Prioritized List of Health Services 410–141–3835
MCE Service Authorization 410–141–3840
Emergency and Urgent Care Services 410–141–3845
Health-Related Services 410–141–3850
Transition of Care 410–141–3855
Pharmaceutical Services 410–141–3860
Integration and Coordination of Care 410–141–3865
Care Coordination Requirements 410–141–3870
Intensive Care Coordination 410–141–3875
MCE Grievances & Appeals: Definitions and General Requirements 410–141–3880
Grievances & Appeals: Grievance Process Requirements 410–141–3885
Grievances & Appeals: Notice of Action/Adverse Benefit Determination 410–141–3890
Grievances & Appeals: Appeal Process 410–141–3895
Grievances & Appeals: Expedited Appeal 410–141–3900
Grievances & Appeals: Contested Case Hearings 410–141–3905
Grievances & Appeals: Expedited Contested Case Hearings 410–141–3910
Grievances & Appeals: Continuation of Benefits 410–141–3915
Grievances & Appeals: System Recordkeeping 410–141–3920
Transportation: NEMT General Requirements 410–141–3925
Transportation: Vehicle Equipment and Driver Standards 410–141–3930
Transportation: Out-of-Service Area and Out-of-State Transportation 410–141–3935
Transportation: Attendants for Child and Special Needs Transports 410–141–3940
Transportation: Secured Transports 410–141–3945
Transportation: Ground and Air Ambulance Transports 410–141–3955
Transportation: Member Service Modifications and Rights 410–141–3960
Transportation: Member Reimbursed Mileage, Meals, and Lodging 410–141–3965
Reports and Documentation 410–141–5000
FINANCIAL SOLVENCY REGULATION: Definitions 410–141–5005
FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements 410–141–5010
FINANCIAL SOLVENCY REGULATION: Procedure for General Financial Reporting and for Determining Financial Solvency Matters 410–141–5015
FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting 410–141–5020
FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor’s Report 410–141–5025
FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant 410–141–5030
FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition 410–141–5035
FINANCIAL SOLVENCY REGULATION: Accountant’s Letter of Qualifications 410–141–5040
FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers 410–141–5045
FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing 410–141–5050
FINANCIAL SOLVENCY REGULATION: Requirements for Reinsurance 410–141–5055
FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance 410–141–5060
FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements 410–141–5065
FINANCIAL SOLVENCY REGULATION: Letters of Credit 410–141–5070
FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves 410–141–5075
FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions 410–141–5080
FINANCIAL SOLVENCY REGULATION: Transparency 410–141–5085
ASSET VALUATION AND PERMITTED INVESTMENTS: Definitions 410–141–5090
ASSET VALUATION AND PERMITTED INVESTMENTS: Calculation of Value 410–141–5095
ASSET VALUATION AND PERMITTED INVESTMENTS: Assets Other Than Securities 410–141–5100
ASSET VALUATION AND PERMITTED INVESTMENTS: Investments Used to Provide Compensating Balances 410–141–5105
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Required Capitalization 410–141–5110
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Mortgage Loans 410–141–5115
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Real Property 410–141–5120
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Corporate Stocks 410–141–5125
ASSET VALUATION AND PERMITTED INVESTMENTS: Loans 410–141–5130
ASSET VALUATION AND PERMITTED INVESTMENTS: Investments 410–141–5135
ASSET VALUATION AND PERMITTED INVESTMENTS: Personal Property 410–141–5140
ASSET VALUATION AND PERMITTED INVESTMENTS: “Prudent Investor” Standard 410–141–5145
ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Conduct by Directors, Trustees, Officers, Agents or Employees 410–141–5150
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Funds in Obligations That Are Not Investment Quality 410–141–5155
ASSET VALUATION AND PERMITTED INVESTMENTS: Approval by Board 410–141–5160
ASSET VALUATION AND PERMITTED INVESTMENTS: Record of Investments 410–141–5165
ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Investments 410–141–5170
CAPITALIZATION: Capital and Surplus 410–141–5175
CAPITALIZATION: Impaired Capital and Surplus 410–141–5180
CAPITALIZATION: Dividend and Distribution Restrictions 410–141–5185
CAPITALIZATION: Restricted Reserve Account 410–141–5190
CAPITALIZATION: Surplus Notes 410–141–5195
CAPITALIZATION: Risk-based Capital (RBC) Definitions 410–141–5200
CAPITALIZATION: RBC Reports 410–141–5205
CAPITALIZATION: Company Action Level Event 410–141–5210
CAPITALIZATION: Regulatory Action Level Event 410–141–5215
CAPITALIZATION: Authorized Control Level Event 410–141–5220
CAPITALIZATION: Mandatory Control Level Event 410–141–5225
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Extraordinary Dividends and Other Distributions 410–141–5230
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Acquisitions And Dispositions Of Assets, and Changes to Ceded Reinsurance Agreements 410–141–5235
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Materiality and Reporting Standards for Asset Acquisitions and Dispositions 410–141–5240
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Materiality and Reporting Standards for Changes in Ceded Reinsurance Agreements 410–141–5245
EXAMINATIONS: CCO Production of Books and Records 410–141–5250
EXAMINATIONS: Authority Examinations of CCOs 410–141–5255
CCO ACQUISITIONS AND MERGERS: Purpose 410–141–5260
CCO ACQUISITIONS AND MERGERS: Activities Prohibited Unless Certain Provisions Satisfied 410–141–5265
CCO ACQUISITIONS AND MERGERS: Procedure For Acquiring Controlling Interest 410–141–5270
CCO ACQUISITIONS AND MERGERS: Information to Be Included in Form A 410–141–5275
CCO ACQUISITIONS AND MERGERS: Hearing, Request, Notice 410–141–5280
CCO ACQUISITIONS AND MERGERS: Determination Concerning Proposed Activity, Time For Decision, Grounds For Refusal 410–141–5285
CCO HOLDING COMPANY REGULATION: Definitions 410–141–5290
CCO HOLDING COMPANY REGULATION: Members of Holding Company Systems 410–141–5295
CCO HOLDING COMPANY REGULATION: Form and Contents of Registration Statement 410–141–5300
CCO HOLDING COMPANY REGULATION: Registration Statement Filing 410–141–5305
CCO HOLDING COMPANY REGULATION: Information Required to Be Disclosed 410–141–5310
CCO HOLDING COMPANY REGULATION: Presumption of Control 410–141–5315
CCO HOLDING COMPANY REGULATION: Disclaimer of Affiliation 410–141–5320
CCO HOLDING COMPANY REGULATION: Transactions Within Holding Company 410–141–5325
CCO HOLDING COMPANY REGULATION: Director and Officer Liability 410–141–5330
CCO HOLDING COMPANY REGULATION: Annual Enterprise Risk Report 410–141–5335
CCO HOLDING COMPANY REGULATION: Disclaimers and Termination of Registration 410–141–5340
CCO HOLDING COMPANY REGULATION: Forms 410–141–5345
CCO HOLDING COMPANY REGULATION: Forms 410–141–5350
CCO HOLDING COMPANY REGULATION: Forms 410–141–5355
CCO HOLDING COMPANY REGULATION: Forms 410–141–5360
CCO INSOLVENCY AND DISSOLUTION: Access to Funds and Transition of Members and Records 410–141–5365
CCO INSOLVENCY AND DISSOLUTION: Hazardous Operations 410–141–5370
CCO INSOLVENCY AND DISSOLUTION: Recovery From Parent Corporation Or Holding Company In The Event Of Liquidation Or Rehabilitation 410–141–5375
CCO INSOLVENCY AND DISSOLUTION: Voluntary Dissolution 410–141–5380
CIVIL PENALTIES
Last Updated

Jun. 8, 2021

Rule 410-141-3885’s source at or​.us