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Oregon Health Plan (OHP) Decision Notices

What Happens if OHP Denies, Stops or Reduces Coverage for a Service?

Your coordinated care organization (CCO) or Oregon Health Authority (OHA) will send a decision notice. They can be for any medical, dental, behavioral health or transportation service your provider has ordered. These letters are also called:

  • Notice of Adverse Benefit Determination
  • Denial Notice
  • Notice of Denial

This letter explains why the CCO or OHA made their decision. These notices are important because they explain what to do if you disagree with the decision.

What Decision Notices Need to Say

Every notice must:

  • Clearly state that it is a Notice of Adverse Benefit Determination
  • List a date of notice
  • List an effective date
  • List the provider who has requested the service, treatment or item
  • Clearly explain why the CCO or OHA made the coverage decision
  • List the Oregon Administrative Rules used to make the decision
  • Give you a contact number to get information that was used to deny the requested service or item, and
  • Give you a contact number to call if you have questions about the information in the notice.

In addition, the notice must include information about:

  • Your hearing rights, if you are not in a CCO
  • How to appeal the decision, if you are in a CCO
  • If a service/item is stopped, how you can keep getting it while you wait for the appeal or hearing
  • How to ask for an expedited (fast) appeal or hearing.

If You Didn't Get a Notice about Services You No Longer Get:

If your health care provider tells you that you will need to pay for a service that is not covered, ask to get a Notice of Adverse Benefit Determination that shows the service is not covered. Once you have it, you can ask for an appeal with your CCO or a hearing with OHA (if you are not enrolled in a CCO). If you did not receive a notice, ask your CCO or OHA to send you one.

These Notices Do Not Mean You Have to Pay

These notices are to let you know that your CCO or OHA will not cover the service.

  • First, you can ask the CCO and OHA to review that decision.
  • If you still want the service, you would need to agree to pay for the service before your provider can give you the service or bill you for it.


Member Resources

Appeals and hearings

OHP contacts

OHP handbooks

Words to know


We want to make sure you have the information you need. 

Talk to your CCO

 Not in a CCO? Call 1-800-273-0557 or

 Email us