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Appeals Guide

We hope this guide provides you with the answers you are seeking about the appeals process. Please contact the Grievance & Appeals Department at (541) 330-4992 with any questions.

Provider Appeals

Contracted Providers

As a contracted provider, you have the opportunity to request that the Plan reconsider a coverage action/decision that affects you adversely. This is the one and only level of appeal available to providers. For PacificSource Community Solutions members, please submit a detailed request using the Plan’s PacificSource Community Solutions Provider Appeal Form.

You should include, at a minimum, a detailed description of the issue in dispute, the basis for your request, as well as all evidence and documentation supporting your position.

The Plan will consider appeals to be timely when they are received within 60 calendar days of the denial date. If you fail to submit a complete and timely appeal, the Plan will consider that you have accepted our coverage determination and have waived further appeal processes regarding the issue. Note that the Plan may consider an exception to the filing timelines (within reasonable limits) if you can show good cause that prevented timely filing due to circumstances beyond your control.

Non-Contracted Providers

The Plan does not offer appeal rights to non-contracted providers. For claims denied due to timely filing and coding reasons, then a non-contracted provider may resubmit the claim through the Claim Reconsideration process (by submitting a corrected claim with clearly marked corrections or resubmitting with supporting documentation). If a claim is denied due to lack of pre-authorization or as untimely because a Plan member failed to provide correct coverage information (i.e. ID card), then the non-contracted provider may bill the member, in accordance with rules established by the Division of Medical Assistance Programs.

Plan members have appeal rights as provided by the Division of Medical Assistance Programs, which are distinct from provider appeals. These rights are described in their Member Handbook and Notices of Action.

Authorization Appeals

If the appeal involves utilization management issues, please note that we only reconsider a non-coverage decision if you provide additional information, not previously reviewed by the Plan, that you believe will impact our original decision. These types of appeals should include supporting medical information indicating why the original decision should be overturned. Appeals based on a denial of coverage as experimental/investigational should also include peer-reviewed literature supporting your position. We respect individual opinions; however, indicating a disagreement with a coverage decision, without providing additional information to support further review, may result in rejection of the appeal.

Every effort is made by appeal representatives to process your requests as quickly as possible. The Plan will consider expediting a decision if a physician requests it, with clear indication that potentially waiting up to 30 calendar days (this is not typical) to receive a coverage determination may place the patient’s health in jeopardy. E.g., the Plan will not rush the review of a MRI coverage appeal because the procedure is scheduled to occur prior to the 30-day timeframe. When the Plan accepts a request to expedite a review, a response will be issued within 72 hours of receipt.

When authorizations have been denied because the Plan reviewer requested additional documentation but did not receive it in a timely manner (such as with pharmacy requests), you should not submit a provider appeal. In these cases, it is more appropriate to submit a new pre-authorization request with the additional information. This is to your benefit, as it is a faster process.

Claim Appeals

If your appeal involves claim issues, please include clear documentation that will help us investigate the claim in question.

In cases where a claim payment denial is considered member responsibility (e.g. instances where the member signed a valid waiver in advance, accepting financial responsibility for the services received), then the member may file an appeal on his/her own behalf, following the member appeals process. This does not prohibit you from also filing an appeal for payment. If you appeal a claim denial where the member has signed a valid waiver and the denial is upheld by the Plan as member responsibility, then you may bill the member for the services. However, in cases where the provider office did not obtain a valid waiver from the member and the denial is upheld, then per Oregon Administrative Rules the member may not be billed.

(Please note that OAR 410-120-1280 prohibits providers from billing Oregon Health Plan members for services/treatment that has been denied due to provider error, such as prior authorization not obtained or required documentation not submitted. Please see our guideline Billing of PacificSource Community Solutions Members))

Claims denied for reasons such as invalid coding or invalid place of service, etc, should not be submitted for reconsideration via the appeals process. In these cases, it is more appropriate to contact the Plan’s Claims Department with your reconsideration request. This also applies to disputes related to duplicate claims, eligibility vs. date of service, sterilization consent forms, and timely filing denials.

The Plan makes every effort to publish and make available our pre-authorization requirements. However, typical claim appeals involve denials based on lack of pre-authorization. These are some examples of provider explanations that may result in upheld denials.

  • Provider used an incorrect pre-authorization grid, or states were unaware of pre-authorization requirements.
  • Provider did not confirm member’s coverage prior to provision of services, and was unaware of, or did not follow pre-authorization requirements.
  • Provider’s records indicate accurate coverage information. However, staff did not contact Plan to obtain a pre-authorization.
  • Provider failed to call with UR information on inpatient services and did not obtain pre-authorization for an admit/stay.
  • The treating provider states that the referring provider did not obtain a pre-authorization. The Plan considers that it is the responsibility of both providers (and it is to the treating provider’s benefit) to confirm pre-authorization.

We remind all providers that it is to your benefit to confirm a pre-authorization is in place prior to rendering services.

Appeal Resolutions

Reviewers not involved in the initial coverage determination participate in the appeal resolution, which is issued to the appealing provider in writing within 30 calendar days of receipt of the appeal. This timeframe may be extended if the reviewer requires additional information to make a determination, and this is of benefit to the member or provider.

All appeals are subject to Plan benefits, medical necessity, coverage criteria, and member’s enrollment status at the time of service.

Member Appeals

Plan members have additional appeal rights as provided by the Division of Medical Assistance Programs, which are distinct from provider appeals. These rights are described in their Member Handbook and Notices of Action.

Additionally, a physician may support a member’s request for an expedited (72-hour) appeal either orally (by calling the Grievance & Appeals Department at (541) 330-4992) or in writing (fax (541) 322-6424). The Plan will resolve a member’s expedited appeal within 72 hours of receipt, if it includes physician’s support indicating that potentially waiting up to 30 calendar days for a decision may place the member’s health or life in jeopardy.