Learn more about what clients can do when they disagree with a plan or DMAP decision about paying for health care services.
Q: How do OHP clients know if a health care service isn't covered?
A: OHP managed care plans are required to send out a denial letter (called Notice of Action) to their members, as defined in OAR 410-141-0260, which includes the denial of payment for services.
All providers should let their patients know whether or not the service is covered before delivering the service. If the client still wants the service, the provider should have the client sign a waiver, as required by OAR 410-120-1280. The waiver shows that the client understands the service is not covered and that payment for the service is the client's responsibility.
Q: If the service has already been delivered, can a client appeal the denial of payment?
A: An OHP managed care plan member is entitled to an appeal of the plan's decision to deny payment of a claim. If the denial is upheld at appeal, the managed care plan must issue a Notice of Appeal Resolution with the client's right to request a hearing.
If the member then files a request for hearing, DMAP will determine whether or not the issue is hearable. This depends on whether or not the member was billed for the service. If the member was billed, the provider must have a valid waiver indicating patient responsibility for payment of the non-covered service. If the member was not billed, the issue is between the provider and the managed care plan.
Q: Can a provider appeal a decision regarding the denial of payment for services?
A: Yes. A provider can appeal the decision through the managed care plan and then, if not resolved through this process, may ask for an administrative review by DMAP in accordance with OAR 410-120-1560 through 410-120-1720.
Q: Can a provider represent a client in an appeal with the managed care plan regarding the denial of payment for services?
A: Anyone the client so designates can represent the client in an appeal or hearing regarding the denial of payment for services. The client must provide written consent.
Q: Are there federal rules about a client's right to a hearing?
A: Yes. The Code of Federal Regulations (CFR) governs hearing rights. 42 CFR 431.220(b) says we need not grant a hearing when the only issue is a federal or state law that requires an automatic change that adversely affects some or all recipients.
Q: Do clients have appeal rights when they are disenrolled from a managed care plan?
A: Yes. Our rules list the conditions for disenrollment. The managed care plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080).
To get a hearing, clients must complete the Request for Administrative Hearing form within 45 calendar days of date on the client notice.
Q: Do managed care plans address complaints about copayment amounts? (OHP Plus and OHP with Limited Drug only)
A: We expect managed care plans to address member complaints under certain conditions. We do not require it for complaints about issues that are not eligible for a contested case hearing. We require managed care plans to have complaint procedures and processes. Our rules spell out these requirements. (See OAR 410-141-0260 through OAR 410-141-0264.) Appeals are also governed by our rules. (See OAR 410-120-1860.)