OAR 436-015-0080
Suspension; Revocation
(1)
Under ORS 656.260 (Certification procedure for managed health care provider), the director may suspend or revoke an MCO’s certification if:(a) The director finds a serious danger to the public health or safety;
(b) The MCO is not providing services according to the terms of the certified MCO plan;
(c) There is a change in legal entity of the MCO that does not conform to the requirements of these rules;
(d) The MCO fails to comply with ORS chapter 656, OAR 436-009, 436-010, 436-015, or orders of the director;
(e) The MCO or any of its members commits any violation for which a civil penalty could be assessed under ORS 656.254 (Medical report forms) or 656.745 (Civil penalty for inducing failure to report claims);
(f) Any false or misleading information is submitted by the MCO or any member of the organization;
(g) The MCO continues to use the services of a health care practitioner whose license has been suspended or revoked by the licensing board; or
(h) The director determines that the MCO was or is formed, owned, or operated by a non-qualifying employer.
(2) The director will provide the MCO written notice of intent to suspend the MCO’s certification.
(a) The notice will:
(A) Describe generally the acts of the MCO and the circumstances that would be grounds for suspension; and
(B) Advise the MCO of its right to a show cause hearing and the date, time, and place of the hearing.
(b) The director will serve the notice upon the MCO’s designated in-state communication liaison and to the registered agent or other officer of the corporation upon whom legal process may be served at least 30 days before the scheduled date of the hearing.
(3) The show cause hearing on the suspension must be conducted as provided in OAR 436-015-0008 (Request for Review before the Director)(6).
(4) An order of suspension will suspend the MCO’s authority to enter into new contracts with insurers for a specified period of time up to a maximum of one year. During the suspension, the MCO may continue to provide services under the contracts in effect at the time of the suspension.
(a) The director may set aside the suspension before the end of the suspension period if the director is satisfied of the MCO’s current compliance, ability, and commitment to comply with ORS chapter 656, OAR 436-009, 436-010, 436-015, orders of the director, and the certified MCO plan.
(b) Before the end of the suspension period the director will determine if the MCO is in compliance with ORS chapter 656, OAR 436-009, 436-010, 436-015, orders of the director, and the certified MCO plan. If the MCO is in compliance the suspension will terminate on its designated date. If the MCO is not in compliance the suspension may be extended beyond one year without further hearing, or revocation proceedings may be initiated.
(5) The process for revocation of the certification of an MCO is as follows:
(a) The director will provide the MCO with notice of an order of revocation which:
(A) Describes generally the acts of the MCO and the circumstances that are grounds for revocation; and
(B) Advises the MCO that the revocation will become effective within 10 days after service of such notice upon the MCO, unless within 10 days the MCO corrects the grounds for the revocation to the satisfaction of the director or the MCO files an appeal as provided in OAR 436-015-0008 (Request for Review before the Director)(7).
(b) The director will serve the order upon the MCO’s designated in-state communication liaison and to the registered agent or other officer of the corporation upon whom legal process may be served.
(c) A show cause hearing on the revocation will be conducted as provided in OAR 436-015-0008 (Request for Review before the Director)(6).
(d) If the director affirms the revocation, the revocation is effective 10 days after service of the order upon the MCO unless the MCO appeals the order.
(6) After revocation of an MCO’s authority to provide services under these rules has been in effect for three years or longer, the MCO may petition the director to restore its authority by making application as provided in these rules.
(7) Notwithstanding section (5) of this rule, in any case where the director finds a serious danger to the public health or safety and sets forth specific reasons for such findings, the director may immediately revoke the certification of an MCO without providing the MCO a show cause hearing. Such order will be final, unless the MCO requests a hearing as provided in OAR 436-001-0019 (Requests for Hearing) within 60 days of the mailing date of the order revoking the MCO certification.. OAR 436-015-0008 (Request for Review before the Director)(6) outlines the process for review.
(8) Insurer contractual obligations to allow an MCO to provide medical services for workers are null and void upon revocation of the MCO certification by the director.
Source:
Rule 436-015-0080 — Suspension; Revocation, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-015-0080.