Current through Register Vol. 63, No. 9, September 1, 2024
(1)
Requirements for patient appeals of financial assistance determination are
effective January 1, 2025.
(2)
Hospitals must document their financial assistance appeals process in their
financial assistance policy.
(3) A
patient may only appeal determinations based on applications for financial
assistance.
(4) If a hospital
denies an application for financial assistance, finds the application to be
incomplete or missing documentation, or provides a patient cost adjustment for
less than 100% of the patient costs, the hospital must, within ten (10)
business days, notify the patient of their ability to take corrective action or
appeal the determination. The notification must meet the following criteria:
(a) The notification must be written in plain
language and either the preferred language of the patient or otherwise in
alignment with the translation standards specified in ORS
442.614.
(b) The notification may be delivered by
mail, email, in person, or through an online portal, if the patient is a
registered user of the hospital's portal. The notification must be delivered
separately and in addition to any financial assistance statements included on
billing statements.
(c) The
notification must clearly specify whether the application was incomplete or if
the patient was denied due to not meeting eligibility criteria.
(A) If the application is found to be
incomplete, missing documentation, or containing errors, the notification must
designate the application as incomplete and requiring further action by the
patient. The notice must further clearly describe the deficiencies and the
actions the patient can take to complete the application by correcting the
deficiencies.
(B) If the
application was denied based on a failure to meet eligibility criteria, the
notification must specify the relevant eligibility criteria and provide contact
information so that the patient can request further information about the
relevant eligibility criteria and the information that was used by the hospital
to reach its determination.
(d) The notification must include a clear
description of how the patient may submit corrections or additional
documentation and how the patient may request an appeal. At a minimum, a
patient must be able to submit corrections or additional documentations and
request an appeal electronically, by either email or through a secure online
portal, by mail, and by in-person delivery.
(e) The notification must inform the patient
that if the patient chooses to appeal, the patient may request review by the
hospital's Chief Financial Officer or a designee of the hospital's Chief
Financial Officer who has been delegated decision-making authority over the
appeal.
(f) The notification must
inform the patient that the patient may also submit an appeal through a written
statement or other supporting documentation.
(g) The notification must provide contact
information to an appropriate hospital representative who may answer questions
about the appeals process or the patient's financial assistance
application.
(5) A
hospital must allow a patient the remaining duration of the 240-day application
period after the date of the first post-discharge billing statement for the
care provided, as specified in 26 CFR 1.501(r)-1(b)(3), or 45 days from the
date the patient was notified of the financial assistance determination to
correct deficiencies in the application or request an appeal, whichever is
greater. A hospital may conduct standard billing practices during the
application period if there is not a pending appeal. However, this does not
remove the hospital's obligation to reimburse a patient if found to be eligible
for financial assistance, in accordance with ORS
442.615.
(6) During the pendency of an appeal a
hospital must:
(a) Suspend all collection
activities if the hospital has initiated collection activities; and
(b) If the hospital has sold the debt under
appeal to a collection agency or has authorized a collection agency to collect
debts on behalf of the hospital, the hospital must notify the collection agency
to suspend collection activities; and
(c) Provide the patient with a written
statement, delivered in accordance with OAR
409-023-0125(4)(b),
and any request by the patient to use a specific, permitted, different delivery
method, that contains:
(A) Confirmation of
receipt of the patient's appeal request;
(B) Notice that:
(i) The hospital has suspended all collection
activities that it has initiated; and
(ii) If the hospital has sold debt to a
collection agency or authorized a collection agency to collect debts on behalf
of the hospital, that the hospital has notified the collection agency to
suspend collection activities.
(C) Information on any actions the patient
may take if a patient has requested a review by the hospital's Chief Financial
Officer or a designee.
(7) If it is determined by the hospital
officer with the authority to determine the appeal that the patient must
provide additional information, the patient must be allowed an additional 45
days, minimum, to provide the requested information. This additional time
period runs from the date the hospital officer with the authority to determine
the appeal informs the patient that they must supply additional
information.
(8) A hospital may
allow for multiple meetings to make a decision about the appeal.
(9) A hospital must allow for a third party
acting with consent and on behalf of the patient to take action on a patient's
application and/or represent the patient on appeal. A hospital may require
documentation of consent to representation from the patient.
(10) A hospital must issue a written
determination on the appeal within 30 days of either the date of the final
appeals meeting or the date of receipt of corrections related to application
deficiencies, whichever is later. The hospital must communicate its
determination in accordance with plain language and preferred language
requirements established in OAR
409-023-0125(4)(a)
and it must be delivered in accordance with OAR
409-023-0125(4)(b),
and any request by the patient to use a specific, permitted, delivery method.
(a) If the final determination results in a
denial of financial assistance, the hospital must also notify the patient of
the date on which suspended collection activities, if any, will
resume.
(b) A hospital may not
resume suspended collection activities until a patient is notified of the final
determination.
(11) A
patient who has taken corrective action on an application that was determined
to have deficiencies may request an appeal if the application is subsequently
denied based on a failure to meet the hospital's eligibility
criteria.
Statutory/Other Authority: ORS
442.615
Statutes/Other Implemented: ORS
442.614 &
442.615
