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Oregon Bulletin

March 1, 2011

 

Oregon Health Authority,
Oregon Medical Insurance Pool
Chapter 443

Rule Caption: Updates rule to be consistent to the current years benefits and benefit provisions.

Adm. Order No.: OMIP 1-2011

Filed with Sec. of State: 1-26-2011

Certified to be Effective: 1-26-11

Notice Publication Date: 1-1-2011

Rules Amended: 443-002-0070

Subject: Updates this administrative rule to be consistent with the 2011 benefits, benefit limitations, benefit exclusions, and claims administration, based on the terms of the contract, application, member handbook, and benefit and rate instructions.

Rules Coordinator: Linnea Saris—(503) 378-5672

443-002-0070

Benefits, Benefit Limitations, Benefit Exclusions and Claims Administration

Effective January 1, 2011, Benefits, Benefit Limitations, Benefit Exclusions and Claims Administration for the OMIP program are set forth in the OMIP individual benefit plan contracts as of January 1, 2011, the OMIP application as of January 1, 2011, the OMIP handbook as of January 1, 2011, the OMIP Premium Rates and Instructions pamphlet as of January 1, 2011, the OMIP Benefit Summary pamphlet as of January 1, 2011 and any applicable endorsements. These documents are hereby incorporated into this rule by reference.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 735.610(6) & 735.625

Stats. Implemented: ORS 735.600 - 735.650

Hist.: OMIPB 2-2004, f. 12-30-04, cert. ef. 1-1-05; OMIPB 2-2005, f. 12-30-05, cert. ef. 1-1-06; OMIPB 1-2007(Temp), f. & cert. ef. 7-23-07 thru 1-5-08; OMIPB 1-2008, f. & cert. ef. 1-2-08; OMIPB 1-2008(Temp), f. & cert. ef. 2-12-09 thru 8-10-09; OMIPB 2-2009, f. 3-30-09, cert. ef. 4-15-09; OMIPB 1-2010, f. & cert. ef. 2-9-10; OMIP 1-2011, f. & cert. ef. 1-26-11

 

Rule Caption: Updates language to mirror enrollee’s contract/
policy and align with current processing procedures and administration.

Adm. Order No.: OMIP 2-2011

Filed with Sec. of State: 1-26-2011

Certified to be Effective: 1-26-11

Notice Publication Date: 1-1-2011

Rules Amended: 443-002-0190

Subject: This rule filing updates language to mirror current contract language and administration. The current language uses the terms “member”, “enrolled dependent”, which OMIP does not define. OMIP is replacing all of these terms with the term “enrollee”. Furthermore, in 2009 OMIP updated the number of days by which an enrollee has to file for an appeal in the benefit contracts to 30 from 180 calendar days, but inadvertently did not update the rule at that time; therefore, the language in the current rule is not consistent with the language used in the current enrollee’s policy/contract.

Rules Coordinator: Linnea Saris—(503) 378-5672

443-002-0190

Grievance, Appeals, External Review

(1) If an enrollee believes that a contract, action, or decision of OMIP is incorrect, the enrollee may file a written grievance or appeal.

(2) The enrollee must first submit a written statement to the Administering Insurers Customer Service Department, within 180 days after the adverse action. containing all the information necessary to explain the issue.

(a) The Administering Insurer will respond to the enrollee within five business days to acknowledge receipt of the grievance and initiate a formal review.

(b) The Administering Insurer will send a written decision to the enrollee within 30 calendar days after receiving the grievance. In the event more extensive review is needed, the Administering Insurer will notify the applicant or member of the delay and will send a written response to the applicant or member within 45 calendar days after receiving the grievance.

(3) If, after filing a grievance, the enrollee is dissatisfied with the Administering Insurer’s response to the grievance, the enrollee may file an appeal, within 30 calendar days.

(a) The Administering Insurer will respond to the enrollee within five business days to acknowledge receipt of the appeal.

(b) The Administering Insurer will mail a written decision to the enrollee within 30 calendar days after receiving the appeal.

(4) If, after filing an appeal, the enrollee is dissatisfied with the outcome of the appeal determination, the enrollee may file a second appeal directly to OMIP.

(a) The enrollee must file an appeal in writing directly to OMIP within 30 calendar days from the date of the Administering Insurer’s written decision on appeal.

(b) OMIP will respond to the enrollee within five business days to acknowledge receipt of the appeal.

(c) The OMIP administrator will review the appeal. If the appeal is regarding medical necessity, experimental/investigational procedures, or continuity of care, OMIP may request an external review from an Independent Review Organization (IRO), on the enrollee’s behalf.

(d) OMIP will be bound by the decision of the IRO. If an appeal goes to an IRO for an external review, it will be considered the final level of appeal.

(e) For appeals not involving and external review, OMIP will mail a written decision to the enrollee within 30 calendar days after receiving the appeal.

Stat. Auth.: ORS 735.610(6)

Stats. Implemented: ORS 735.600 - 735.650

Hist.: OMIPB 2-2004, f. 12-30-04, cert. ef. 1-1-05; OMIPB 2-2010(Temp), f. & cert. ef. 9-29-10 thru 3-27-11; OMIP 2-2011, f. & cert. ef. 1-26-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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