Oregon Health Plan - If You are Denied Services or Have a Complaint
Authored By: Oregon Law Center and Legal Aid Services of Oregon
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1. I'm On Oregon Health Plan but the Medical Services I Need Were Denied. What Can I Do?
If you are in a CCO:
If you have been denied medical services, or your medical services have been reduced or cut off, you have to be given a notice and have a right to appeal the decision. If you get your medical care through a Coordinated Care Organization (CCO), the decision has to be by the CCO, not just the doctor. If a doctor denies a service or refuses to make a referral to a specialist, for example, you need to ask the doctor's office to make a request to the CCO in order to get a denial notice, called a "Notice of Action," from the CCO, or you can contact the CCO and request a denial notice so that you have hearing and appeal rights. The Notice must tell you about your hearing and appeal rights. OAR 410-141-3263
When the provideer or CCO denies a service, there are two ways to challenge the denial. The first is to "appeal to the CCO. Your notice and your member handbook will tell you how to do that. You must do that within 45 days from the date on the notice. The CCO has 16 days to make a decision. OAR 410-141-3262
If you still don't agree with the plan's decision, you can ask OHA for a hearing within 45 days from the date of the CCO's Notice of Appeal Resolution. See section 2 for information about how to request a hearing. OAR 410-141-3264
You don’t have to appeal to the CCO first in order to get a hearing. You can just ask for a hearing within 45 days after the CCO’s Notice of Action. It is better to file a hearing request with the OHA instead of filing an appeal with the CCO. The reason is that when you ask for a hearing, the OHA will ask the CCO to review your case and make another decision. If the CCO approves the benefits, you won’t have to go to a hearing. If the CCO still denies the benefits, you won’t have to ask for a hearing again, so you won’t have to worry about filing another form and meeting another deadline. OAR 410-141-3264
If you are not in a CCO but are in "Fee for Service" (Open Card):
If you are "fee-for-service" (open medical card) then the decision notice will come from DMAP and it will have information about your hearing rights. OAR 410-120-1860
2. How Do I Ask for a Hearing?
In order to have a hearing, you must fill out a hearing request form. To get this form, ask your CCO or go to your local DHS office and ask the receptionist for a DHS Form 443 (Administrative Hearing Request). You can also get it on the Internet. (Go to www.oregon.gov/dhs. Click on “Find a Form” on the left side of the web page. Type in “443” for the number and click on “Search.”
To find out about your hearing rights, call the Public Benefits Hotline (1-800-520-5292) or your local Legal Aid office for possible advice or representation. Go to http://oregonlawhelp.org/find-legal-help/directory for a directory of legal aid programs.
The hearing request form must be received by the OHA Hearings Unit within 45 days from the date of the written notice you get whether it’s from the CCO or OHA. You can take the hearing request form to your local DHS office and file it there. They will send it to OHA for you. If you file your appeal with the CCO first, you have 45 days to request a hearing from the date on the “Notice of Appeal Resolution” (the notice your CCO will send you to let you know the results of your CCO appeal).
You have a right to an interpreter at the hearing. You can put your request for an interpreter in when you request the hearing.
In cases where your medical services were reduced or cut off, you might have the right to continued medical services while you are waiting for the appeal from your CCO or for the hearing. But, you have to ask for the services to be continued right away. OAR 410-141-3260(16); 410-120-1865
3. What Happens at a Hearing?
A state administrative law judge (ALJ) conducts the hearing. The ALJ is part of the Employment Department Office of Administrative Hearings. The hearings are usually held over the telephone. Someone from the OHA will represent the OHA. If you are in a CCO, someone from your CCO will be at the hearing. You also will be asked to testify and you have the right to present evidence and witnesses. The ALJ will write a decision based on the evidence and the law. The CCO and OHA are required to obey the ALJ’s decision. OAR 410-120-1875; OAR 137-003-0600; 137-003-0605
4. What if I Am Unhappy with the Service or Someone Was Rude to Me?
CCO members who are not satisfied with the services they get under the Oregon Health Plan have the right to file a complaint.
You can file a complaint if you have a general concern about your care or services. Examples include:
- rude treatment,
- a delay in getting an appointment
- a really long wait at the doctor's office
- a refusal to get you an interpreter if you do not speak English well
5. How Do I File a Complaint?
Every CCO is required to have written procedures for taking complaints. Your CCO member handbook will describe the complaint process. Many CCOs have forms to use when filing a complaint.
You can either give the complaint in writing or tell the doctor or office staff about your complaint. (It is a good idea to give a written complaint, even if you have talked about the problems with the doctor or office staff.) If you tell someone you have a complaint, the doctor or office staff should tell you how the complaint process works.
OAR 410-141-0260(4); OAR 410-141-0261(1) (a) (B)
6. When Can I Expect a Response to My Complaint?
The CCO should make a decision about your com-plaint within 5 work days, but they may take up to 30 days to resolve the complaint if they need more time. If you told them about your complaint and did not write it, they can make their decision by telling you instead of writing it. If you wrote the complaint, they have to write the decision.
OAR 410-141-0261(4), (5)
7. Other Than a Complaint or Hearing, Are There Other Ways to Get Help for a Problem With the Oregon Health Plan?
Yes. Another way to get help is to call the Governor's Advocacy Office at 1-800-442-5238 or the Client Services Unit of OHA at 1-800-273-0557. The Oregon Health Plan also has an Ombudsperson who can help you. The toll free telephone number for the Ombudsperson is (1)(877) 642-0450, or you can call (503) 947-2346.