Or. Admin. Code § 836-053-1140

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

Section 836-053-1140 - Appeal, Utilization Review Determinations

(1) When a provider first appeals the decision of an insurer to deny treatment or payment for services as not medically necessary or experimental under ORS 743.807(2)(c):

(a) The insurer shall acknowledge receipt of the notice of appeal not later than the seventh day after receiving the notice; and

(b) An appropriate medical consultant or peer review committee shall review the appeal and decide the issue not later than the 30th day after the insurer receives notice of the appeal.

(2) A standard for timeliness in section (1) of this rule does not apply when:

(a) The period of time is too long to accommodate the clinical urgency of the situation;

(b) The provider does not reasonably cooperate; or

(c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise.

(3) An insurer shall treat an appeal from a decision by a medical consultant or peer review committee pursuant to section (1)(b) of this rule as an internal appeal under the insurer's grievance procedures under ORS 743.804(3).

(4) Nothing in this rule shall prevent an enrollee from filing an internal appeal under the insurer's regular grievance procedure established pursuant to ORS 743.804 when the grievance concerns an adverse benefit determination, but this rule does not entitle a person not otherwise allowed to file a grievance or to appeal a decision by a medical consultant or peer review committee to file such a grievance or appeal.

Or. Admin. Code § 836-053-1140

ID 1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804, 743.806 & 743.807