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External review of healt​h care decisions

Expedited External Review Eligibility

ORS 743B.252 requires that insurers forward all requests for external review to the Division of Financial Regulation. Upon receipt of a written request from a patient or patient's representative for external review, the insurer must review the request for expedited external review eligibility. Insurers shall expedite an external review request if the request meets one of the scenarios below:

  • If the adverse benefit determination concerns an admission, the availability of care, a continued stay or a health care service for a medical condition for which the enrollee received emergency services, as defined in ORS 743A.012, and has not been discharged from a health care facility.
  • If a provider with an established clinical relationship to the enrollee certifies in writing and provides supporting documentation that the ordinary time period for external review would seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.
  • An enrollee requests external review before the enrollee has exhausted all internal appeals.
  • An enrollee simultaneously requests an expedited internal appeal and an expedited external review.

Referral form

Questions?

Oregon External Review Staff
Exreview.Ins@dcbs.oregon.gov
503-947-7268

HIPAA release forms

As of 1/1/2021, HIPAA release forms are no longer required to process external review requests per HB 2046.

Forward request

Upon receipt of a request for an external review, either expedited or standard, the insurer must:

Deadlines for referrals

  • Insurers must forward standard referrals within two days.
  • Insurers must immediately forward expedited review referrals.

The independent review organization's (IRO) first task is to determine whether the case is eligible for external review per insurance policy and state regulations.

Index and send patient’s record

The Division of Financial Regulation will e-mail the name and contact information of the randomly chosen IRO to the insurer, with instructions to send or fax the patient's medical record and additional information to the IRO. For expedited reviews, the insurer must immediatley fax or overnight the records.

Note: If either the insurer or the enrollee knows of a conflict of interest with the IRO assigned to the case, they must provide evidence to the Division of Financial Regulation within three days of receiving the IRO notification letter. Another IRO will be assigned.

Respond to IRO requests

If contacted by the IRO for more information, the insurer must cooperatively respond to all such requests as quickly as possible.

No Surprises Act:

Regarding Oregon's External Review Process and cases related to NSA Compliance

Oregon is unable to apply HHS's guidance for external review cases with disputes related to reviewing NSA compliance matters. As such Oregon will submit external review cases related to NSA compliance matters directly to the Federal HHS-administered external review process. External Review NSA Guidance 12.29.21 (cms.gov) PDF document icon

The Federal HHS-administered external review process is conducted by a designated federal contractor that performs the administrative functions of external review on behalf of HHS. The Federal HHS-administered external review process can accommodate external review of NSA compliance matters starting January 1, 2022. The Federal contractor is MAXIMUS Federal Services, Inc. (MAXIMUS). MAXIMUS, on behalf of HHS, also provides technical assistance to consumers related to external review requests. Additional information is available at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts  

How to request external review matters:

Fill out the online external review request (the same form for all other Oregon external review requests)

In the “Provider's Specialty who prescribed the treatment that is under review" type in the following phrase: “NSA COMPLIANCE"

By using the above phrase this will notify the Division to forward the request directly to MAXIMUS Federal Services for processing.

MAXIMUS' contact information is:

Maximus Federal External Review
Federal External Review Process – NSA
3750 Monroe Ave., Suite 705
Pittsford, NY 14534
Facsimile: 1-888-866-6190 Phone: 1-888-866-6205
ferp@maximus.com