Or. Admin. Code § 333-004-3170

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-004-3170 - RH Access Fund Claim Re-determination

(1) If an agency disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determination review must be made to the RH Program in writing, within 180 calendar days from the date of the RH Access Fund original claim adjudication date.

(2) All requests must contain a detailed letter of explanation identifying the specific re-determination denial issue and alleged error. This information must be submitted to the RH Program at the time of the request.

(3) At the time the request for re-determination is made an agency is responsible for providing the information needed to adjudicate its claim, including relevant health records and evidence-based practice data to support the position being asserted on review. The RH Program may request additional information that it finds relevant to the review. An agency requesting a re-determination review must include the following:

(a) The specific service, supply or item being denied, and include all relevant codes and a detailed justification for the re-determination of the denied service;

(b) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination; and

(c) Any information or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute.

(4) A re-determination review is based on RH Program review of documentation and applicable law. The RH Program does not provide a face-to-face meeting with an agency as part of the re-determination process.

(a) The agency is responsible for the timely submission of review request and all information pertinent to conducting the review and consistent with the requirements of this rule.

(b) The RH Program shall notify an agency requesting review that the re-determination request has been denied if:

(A) The agency did not submit a timely request;

(B) The required information is not provided at the same time the request is submitted; or

(C) The agency fails to submit any additional requested information within 14 business days of request.

(5) The RH Program's final decision under this rule is an order in other than a contested case under ORS 183.484 and the procedures in OAR 137-004-0080 through 137-004-0092 (Miscellaneous, Orders in Other Than Contested Case) apply.

Or. Admin. Code § 333-004-3170

PH 84-2020, adopt filed 12/18/2020, effective 1/1/2021; PH 192-2022, minor correction filed 09/07/2022, effective 9/7/2022

Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149 & OL 2022, ch. 45, sec. 10

Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032 & OL 2022, ch. 45, sec. 10