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Oregon Bulletin

March 1, 2012

Oregon Health Authority, Oregon Medical Insurance Pool, Chapter 443

Rule Caption: Updates rule to be consistent to the current year’s benefits and benefit provisions.

Adm. Order No.: OMIP 1-2012

Filed with Sec. of State: 1-26-2012

Certified to be Effective: 2-6-12

Notice Publication Date: 1-1-2012

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 OMIP enrollee contract, Member Handbook, Application, 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, 2012, 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, 2012, the OMIP application as of January 1, 2012, the OMIP handbook as of January 1, 2012, the OMIP Premium Rates and Instructions pamphlet as of January 1, 2012, the OMIP Benefit Summary pamphlet as of January 1, 2012 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; OMIP 1-2012, f. 1-26-12, cert. ef. 2-6-12


 

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

Adm. Order No.: OMIP 2-2012

Filed with Sec. of State: 1-26-2012

Certified to be Effective: 2-6-12

Notice Publication Date: 1-1-2012

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” and “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 with the enrollee. The purpose of this rule filing, updates this rule which inadvertently when updated, was not filed in a timely manner with Legislative Counsel.

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

443-002-0190

Grievance, Appeals, External Review

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

(1) To file a grievance the enrollee must submit a written statement to the Administering Insurer within 180 days from the adverse contract, action, or decision, outlining the issue and any other supporting documentation.

(a) The Administering Insurer will respond to the enrollee within five business days from the date the grievance was received, to acknowledge receipt of the grievance.

(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 enrollee of the delay and will send a written response to the enrollee within 45 calendar days after receiving the grievance.

(2) If, after filing a grievance, the enrollee is dissatisfied with the Administering Insurer’s response to the grievance, the enrollee may then file an appeal.

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

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

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

(3) If 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 days from the date of the determination letter regarding the first appeal decision (not grievance) made by the administrating insurer.

(b)(A) OMIP will review the appeal; however, if the dispute is regarding medical necessity, experimental or investigational procedures, or need for continuity of care, OMIP will request an External Review from and Independent Review Organization (I.R.O.) on your behalf.

(B) If OMIP chooses to send an appeal to External Review, it will be considered the final level of appeal. The I.R.O. will make its review and report its decision within 30 calendar yeas (3 days for expedited reviews).

(c) If the appeal is not regarding medical necessity, experimental or investigational procedures, or need for continuity, 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; OMIP 2-2012, f. 1-26-12, cert. ef. 2-6-12

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, 2011.

2.) Copyright 2012 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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