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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.
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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 |