Or. Admin. Code § 333-004-4100

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-004-4100 - Claim Re-Determination

(1) If an authorized agency or authorized provider disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determination review must be made to the RH Program in writing, within 60 calendar days from the date of the original claim adjudication date.

(2) All requests must contain a detailed letter of explanation identifying the specific re-determination denial issue and alleged error. This information must be submitted to the RH Program at the time of the request.

(3) At the time the request for re-determination is made an authorized agency or authorized provider is responsible for providing the information needed to adjudicate its claim, including relevant health records The RH Program may request additional information that it finds relevant to the review. An authorized agency or authorized provider requesting a re-determination review must include the following:

(a) The specific service, supply or item being denied and a detailed justification for the re-determination of the denied service;

(b) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination; and

(c) Any information or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute.

(4) A re-determination review is based on RH Program review of documentation and applicable law. The RH Program does not provide a face-to-face meeting with an authorized agency or authorized provider as part of the re-determination process.

(a) The authorized agency or authorized provider is responsible for the timely submission of review request and all information pertinent to conducting the review and consistent with the requirements of this rule.

(b) The RH Program shall notify an authorized agency or authorized provider requesting review that the re-determination request has been denied if:

(A) The authorized agency or authorized provider did not submit a timely request;

(B) The required information is not provided at the same time the request is submitted; or

(C) The authorized agency or authorized provider fails to submit any additional requested information within 14 business days of request.

Or. Admin. Code § 333-004-4100

PH 47-2023, adopt filed 09/28/2023, effective 10/1/2023

Statutory/Other Authority: ORS 413.042 & OL 2022, Ch. 435 (HB 4034, Section 10)

Statutes/Other Implemented: ORS 413.032 & OL 2022, Ch. 435 (HB 4034, Section 10)