If OHP Decides to Not Cover a Health Care Service, You Have Options.
You will get a decision notice (known as a Notice of Adverse Benefit Determination or Notice of Denial) when your coordinated care organization (CCO) or the Oregon Health Authority (OHA) decides to:
- Not cover a service you or your provider asked for.
- Cover less than what you or your provider asked for, or that you get now.
- Stop covering a service that you get now.
The Notice explains why the CCO or OHA made this decision. It also explains your right to have your CCO or OHA review the decision. If you think OHP should still cover the service:
- If the Notice is from your CCO, you can appeal the decision with your CCO. After the appeal you can also ask the Oregon Health Authority (OHA) for a hearing.
- If the Notice is from OHA, you can ask OHA for a hearing.
After the appeal or hearing, the decision may change, or it may stay the same. Only CCO members can ask for appeals.
OHP Member Appeals
To ask your CCO for an appeal, follow the instructions in the Notice from your CCO.
An appeal is when you ask your CCO to change a decision you disagree with about a service your doctor ordered. You can call, write a letter or fill out a form that explains why the CCO should change its decision. This is called filing an appeal.
Follow the instructions on the notice from your CCO.
Anyone can help you with your appeal. You, your representative, or your provider can file the appeal. This can be over the phone or in writing. Your provider can only file the appeal if you give them written permission to do this.
Your CCO must receive your appeal within 60 days from the date on the Notice of Adverse Benefit Determination.
Ask your CCO for a copy. If the CCO does not have a copy of the notice, tell them why you think you should have received one. Also tell them what service it should be for.
Yes. Your provider may be able to give your CCO more information that helps your CCO understand why you need the health service. Your CCO may be able to cover a different health service that meets your health care needs. Ask your doctor if other services are right for you and if the CCO will cover them.
Your CCO has 16 days to review their decision and any new information you or your provider send them. In some cases, the CCO may ask for another 14 days to complete the review.
When your CCO has completed their review, they must send you a Notice of Appeal Resolution. It will say whether the CCO has changed the original decision or not.
You can ask OHA for an administrative hearing (also called a contested case hearing). You must do this within 120 days from the date on the Notice of Appeal Resolution.
Administrative Hearings
To ask for a hearing, complete our
secure online form or one of these forms:
Send the completed form to OHA within:
- 60 calendar days of the date on the Notice of Denial from OHA, or
- 120 calendar days of the date of the Notice of Appeal Resolution from your CCO.
Frequently Asked Questions
If OHA denied payment, members must ask OHA for a hearing.
If the CCO denied payment, members must first appeal the decision with the CCO.
- The Notice of Action from your CCO explains how to do this.
- The CCO will send the member a Notice of Appeal Resolution at the end of the appeal process.
If the appeal to the CCO does not change the denial, the member can then ask OHA for a hearing. They need to do this within 120 days of the date on the Notice of Appeal Resolution.
The OHP member is only responsible for payment if:
Part (b) of this rule says automatic changes required by federal or state law do not require hearings.
Yes. The OHP member can name anyone as their representative. They can do this on their appeal or hearing request. The CCO must have written consent from the member. OHA will contact the representative listed on the member’s hearing request to confirm.
Yes. Our rules list the conditions the CCO must meet. OHA will only approve disenrollment requests when the CCO meets those conditions. (See OAR 410-141-3810.)
OHA will send you a letter letting you know next steps. If you do not receive that letter within two weeks, please contact the OHA Medical Hearings unit at 503-945-5785 or email OHAMedical.Hearings@odhsoha.oregon.gov.
If the notice is about a service you are already getting, you may be able to ask to keep getting the service if you:
- Ask your CCO or OHA to continue the service when you ask for an appeal or hearing, and
- Do this within 10 days of the effective date on the notice from the CCO or OHA.
If you receive the notice after the effective date on the notice, please call your CCO or OHA for instructions.
If the reviewer agrees with the original decision, you may have to pay for services you receive after the effective date on the notice.
You and your provider may believe that you have an urgent medical, dental or mental health problem that cannot wait. If so:
For appeals:
Tell your CCO that you need a fast (expedited) appeal. - Call or fax your request to your CCO.
- Include a statement from your provider or ask the provider to call and explain why it is urgent.
If your CCO agrees that it is urgent, a staff person will call you with the decision in 72 hours (three days).
For hearings:
- You can also fax your hearing request form (OHP 3302) to the OHP Hearings Unit at 503-945-6035.
- Include a statement from your provider explaining why it is urgent.
If OHA agrees that it is urgent, the Hearings Unit will call you in 72 hours (three days).
When a CCO or OHA denies coverage of services that your provider ordered, your authorized representative or your provider can help you ask for an appeal or hearing.
Flowcharts
English
English Large Print Español / Spanish
Español / Spanish Large Print
Русский / Russian
Tiếng Việt / Vietnamese
اللغة العربية / Arabic
简体中文 / Simplified Chinese
繁體中文 / Traditional Chinese
한국어 / Korean
Af Soomaali / Somali
Lus Hmoob / Hmong
foosun Chuuk / Chuukese
Kajin Majol / Marshallese
Português / Portuguese (Brazilian)