Oregon Health Plan (OHP) Appeals and Hearings

If OHP Decides to Not Cover a Health Care Service, You Have Options.

You will get a decision notice (known as a Notice of Adverse Benefit Determination or Notice of Denial) when your coordinated care organization (CCO) or the Oregon Health Authority (OHA) decides to:

• Not cover a service you or your provider asked for.
• Cover less than what you or your provider asked for, or that you get now.
• Stop covering a service that you get now.

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:

• If the Notice is from your CCO, you can appeal the decision with your CCO. After the appeal you can also ask the Oregon Health Authority (OHA) for a hearing.
• If the Notice is from OHA, you can ask OHA for a hearing.

After the appeal or hearing, the decision may change, or it may stay the same. Only CCO members can ask for appeals.

OHP Member Appeals

To ask your CCO for an appeal, follow the instructions in the Notice from your CCO.

Administrative Hearings

To ask for a hearing, complete our secure online form or one of these forms:

Send the completed form to OHA within:

• 60 calendar days of the date on the Notice of Denial from OHA, or 
• 120 calendar days of the date of the Notice of Appeal Resolution from your CCO.

Frequently Asked Questions

Flowcharts

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