Oregon Bulletin
March 1, 2011
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.
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