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You will get a Notice of Adverse Benefit Determination or Notice of Denial when your coordinated care organization (CCO) or the Oregon Health Authority (OHA) decides to:
The Notice explains why the CCO or OHA made this decision. It also explains your right to have your CCO or OHA review the decision. If you think OHP should still cover the service:
To ask your CCO for an appeal, follow the instructions in the Notice from your CCO.
An appeal is when you ask your CCO to change a decision you disagree with about a service your doctor ordered. You can call, write a letter or fill out a form that explains why the CCO should change its decision. This is called filing an appeal.
Follow the instructions on the notice from your CCO.
Anyone can help you with your appeal. You, your representative, or your provider can file the appeal. This can be over the phone or in writing. Your provider can only file the appeal if you give them written permission to do this.
Your CCO must receive your appeal within 60 days from the date on the Notice of Adverse Benefit Determination.
Ask your CCO for a copy. If the CCO does not have a copy of the notice, tell them why you think you should have received one. Also tell them what service it should be for.
Yes. Your provider may be able to give your CCO more information that helps your CCO understand why you need the health service. Your CCO may be able to cover a different health service that meets your health care needs. Ask your doctor if other services are right for you and if the CCO will cover them.
Your CCO has 16 days to review their decision and any new information you or your provider send them. In some cases, the CCO may ask for another 14 days to complete the review.
When your CCO has completed their review, they must send you a Notice of Appeal Resolution. It will say whether the CCO has changed the original decision or not.
You can ask OHA for an administrative hearing (also called a contested case hearing). You must do this within 120 days from the date on the Notice of Appeal Resolution.
To ask for a hearing, complete our
secure online form or one of these forms:
Send the completed form to OHA within:
If OHA denied payment, members must ask OHA for a hearing.
If the appeal to the CCO does not change the denial, the member can then ask OHA for a hearing. They need to do this within 120 days of the date on the Notice of Appeal Resolution.
Yes. The OHP member can name anyone as their representative. They can do this on their appeal or hearing request. The CCO must have written consent from the member. OHA will contact the representative listed on the member’s hearing request to confirm.
Yes. Our rules list the conditions the CCO must meet. OHA will only approve disenrollment requests when the CCO meets those conditions. (See OAR 410-141-3810.)
OHA will send you a letter letting you know next steps. If you do not receive that letter within two weeks, please contact the OHA Medical Hearings unit at 503-945-5785 or email OHAMedical.Hearings@odhsoha.oregon.gov.
Words to know
410-141-3875: Definitions and General Requirements
410-141-3885: Notice of Adverse Benefit Determination
410-141-3890: Appeal Process
410-141-3895: Expedited Appeal
410-141-3900: Contested Case Hearings
410-141-3905: Expedited Contested Case Hearings
410-141-3910: Continuation of Benefits
410-120-1860: Contested Case Hearing Procedures
We want to make sure you have the information you need.
Talk to your CCO
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