Or. Admin. R. 836-053-1100

Current through Register Vol. 63, No. 8, August 1, 2024

Section 836-053-1100 - Internal Appeals Process

(1) The minimum standards for timeliness of response by an insurer to appeals by its enrollees, for purposes of the system of resolving and appeals required by ORS 743.804 are as follows:

(a) An insurer shall acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal;

(b) An insurer shall make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

(2) An otherwise applicable 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 enrollee 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) For adverse benefit determinations eligible for external review under ORS 743.857, an insurer may waive its internal appeals process at any time. If the insurer waives its internal appeals process, the internal appeals process is deemed exhausted for the purposes of qualifying for external review.

Or. Admin. R. 836-053-1100

ID 1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804