A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
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Oregon General Information and Internal Plan Review: Oregon law requires you to complete up to 3 levels of your health plan’s internal grievance procedure before applying for external review, unless your health plan agrees to waive this requirement. Although you apply through your health plan, the Oregon Insurance Division selects the Independent Review Organization (IRO).
In addition to appeals based on disagreements about medical necessity and whether a procedure is experimental or investigational, Oregon allows appeals regarding "continuity of care." Oregon’s continuity of care rules require managed care plans to continue to provide coverage with a particular provider for a limited period of time if that provider leaves an enrollee’s health maintenance organization (HMO) network while the insured is undergoing an active course of treatment which the provider and patient consider medically necessary.
The External Review Process: Whom to contact: | Contact your health plan | Who can appeal: | Anyone can request external review who is covered by a health benefit plan other than Medicare, the Oregon Health Plan, and employer self-insured plans. | What you can appeal: | You can appeal denials of coverage for services that the health plan considers either experimental or investigational, or not medically necessary. You can also appeal denial of continuity of care with a provider who leaves your HMO. | When you can appeal: | After denial for coverage has been appealed through up to 3 levels of the health plan’s internal process; you must request external review within 180 days from receipt of the final adverse decision. | What to send: | A written request for external review. If the patient is in serious danger of life-threatening injury or impairment pending a 30-day review process, the request should state "expedited review" and include testimony from a health care professional as to the potential danger. | What you must pay: | No charge; all costs are paid by the insurer | What will happen: | Your health plan will forward your request for external review to the State of Oregon’s Insurance Division within 2 days. The Consumer Advocate Liaison will assign your case to an IRO and tell you which IRO will review your case. If there is a conflict of interest, you may challenge the choice of IRO within 2 days of receiving the notice by contacting the Consumer Advocate Liaison.
The IRO will: - Determine if your request qualifies for external review.
- Accept additional information from you, your provider, or your health plan within 7 days.
- Review your case and notify you and your health plan of its decision.
| When you will get a decision: | For a standard review, you will receive a decision from the IRO within 30 days of your request for independent review. | In urgent situations: | You, your provider, or your health plan may submit additional information within 24 hours of an expedited request. An expedited review produces a decision within 3 days of your request. |
How to Get More Information: Oregon Department of Consumer & Business Services, Insurance Division, 503-947-7269
www.oregoninsurance.org/docs/consumer/exreview/external_review_info.htm Information updated as of 8-31-2004 |
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