Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-1100 - Internal Appeals Process

Universal Citation: OR Admin Rules 836-053-1100

Current through Register Vol. 63, No. 9, September 1, 2024

(1) The minimum standards for timeliness of response by an insurer to appeals by its enrollees, for purposes of the system of resolving and appeals required by ORS 743.804 are as follows:

(a) An insurer shall acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal;

(b) An insurer shall make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

(2) An otherwise applicable standard for timeliness in section (1) of this rule does not apply when:

(a) The period of time is too long to accommodate the clinical urgency of the situation;

(b) The enrollee does not reasonably cooperate; or

(c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise.

(3) For adverse benefit determinations eligible for external review under ORS 743.857, an insurer may waive its internal appeals process at any time. If the insurer waives its internal appeals process, the internal appeals process is deemed exhausted for the purposes of qualifying for external review.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.