Or. Admin. Code § 410-141-3910

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-3910 - Grievances And Appeals: Continuation of Benefits

(1) A member who may be entitled to continuing benefits may request and receive continuing benefits in the same manner and same amount while an appeal or contested case hearing is pending:

(a) A member can request continuation of benefits by phone, letter, fax or by using the Review of Health Care Decision form and check the box requesting continuing benefits by:

(A) The tenth day following the date of the notice of adverse benefit determination or the notice of appeal resolution; or

(B) The effective date of the action proposed in the notice, if applicable.

(b) In determining timeliness, delay for good cause as defined in OAR 137-003-0528 is not counted;

(c) The Managed Care Entity (MCE) must continue the member's benefits if all of the following occur:

(A) The appeal involves the termination, suspension, or reduction of previously authorized services;

(B) The services were ordered by an authorized provider;

(C) The period covered by the original authorization has not expired; and

(D) The member timely files for continuation of benefits.

(d) If, at the member's request, the MCE continues or reinstates benefits while the appeal or hearing is pending, the benefits must be continued until one of the following occurs:

(A) The member fails to request a hearing and continuation of benefits within 10 calendar days after the date of the notice of appeal resolution;

(B) The member withdraws the appeal or request for hearing;

(C) A final order resolves the hearing.

(e) Member responsibility for services furnished while the appeal or hearing is pending. If the final resolution of the appeal or hearing is adverse to the member, that is, upholds the MCE's adverse benefit determination, the MCE may recover the cost of services furnished to the member while the appeal and hearing was pending, to the extent that they were furnished solely because of the requirements of this section.

(2) For reversed appeal and hearing resolution services:

(a) Benefits not furnished while the appeal or hearing is pending. If the MCE or the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal/hearing was pending, the MCE shall authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. The MCE must take the following steps:

(A) notify the member, the member's representative (if applicable) both orally and in writing and the member's provider in writing of the available services and how to access them;

(B) Enter the prior authorization into the system or adjust the encounter data claim representing the service.

(b) Benefits furnished while the appeal or hearing is pending. If the MCE or the Administrative Law Judge reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, the MCE or the Authority shall pay for those services in accordance with the Authority policy and regulations.

Or. Admin. Code § 410-141-3910

DMAP 57-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 98-2023, amend filed 12/28/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.032, 414.615, 414.625, 414.635 & 414.651

Statutes/Other Implemented: ORS 414.610 - 414.685