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If your claim was denied

You can appeal an insurance company's decision to deny a claim or a decision to pay less than the amount billed. The Division of Financial Regulation can explain the appeals process. Call one of our consumer advocates or file a complaint to get help. Here is an overview.

Complaint and appeals process

  • Your insurance company must acknowledge nonemergency complaints and appeals within seven days.
  • Your insurance company must make a decision and respond within 30 days.
  • Your insurance company must have a process for responding to emergency complaints (expedited review) more quickly.
  • If your insurance company rejects your first appeal and your plan is through an employer, you may have the right to a second appeal.
  • Your insurance company has seven days to acknowledge each appeal and 30 days to respond.
  • If your insurance company rejects all appeals, you have the right to an independent external review to determine:
    • Whether treatment is medically necessary.
    • Whether treatment is experimental or investigational.
    • Whether treatment is for continuity of care.
    • Other "adverse benefit" issues such as the insurance company rescinded or ended your coverage.

Oregon External Review Process

Under Oregon insurance statutes and rules, you may proceed to an external review after all internal levels of appeal have been exhausted. An exception to this would be if you and the insurer both agree to go directly to external review. The external review process has your case reviewed by a third party unaffiliated with your insurer. When you have applied for an external review your insurer will notify the Division of Financial Regulation of your request for external review. The division will randomly assign your case to an independent review organization (also called an IRO) contracted with the division to perform external reviews. The independent review organization assigned to your case will have one or more medical professionals review all documents and issue a final binding decision to either overturn or uphold the insurer’s denial. Sometimes, the independent review organization may rule that the appeal does not qualify for a full external review and will issue an ineligibility letter.

The external review process is purely a document review process; once the independent review organization has reviewed your case, it will issue a final case synopsis letter detailing the outcome of your case. You can provide any additional documentation directly to the assigned IRO to be ​ I included in during the review.

Types of External Reviews

There are two types of external reviews, a standard review and an expedited review.

A standard review will be completed within 30 calendar days.

An expedited review will be completed within 3 calendar days.

To Request a Standard External Review

To request a standard external review you will need to supply:

  • A written request for external review.
  • A completed HIPAA release form allowing the insurer to provide all your medical records to the independent review organization.

You have 180 calendar days after receiving your final adverse benefit determination letter to submit your request for an external review. Your case will not qualify for a review if you exceed this time frame. You can provide additional information you want reviewed. The Division of Financial Regulation recommends you gather any information you want reviewed before submitting your external review request.

The Division of Financial Regulation offers a consumer preparation checklist to assist with preparing for an external review.

To Request an Expedited External Review

To request an expedited 3-day review you will need to supply:

  • A written request for external review.
  • A completed HIPAA release form allowing the insurer to provide all your medical records to the independent review organization.
  • A letter from your provider that states the ordinary time period for an external review would jeopardize your life or health or your ability to regain maximum function.
  • Documentation that supports your provider’s recommendation for an expedited review.

You have 180 calendar days after receiving your final adverse benefit determination letter to submit your request for an external review. Your case will not qualify for a review if you exceed this time frame. You can provide additional information you want reviewed. The Division of Financial Regulation recommends you gather any information you want reviewed before submitting your external review request.

The Division of Financial Regulation offers a consumer preparation checklist to assist with preparing for an external review .

External Review Criteria

Your insurer may provide you with advice on whether or not it believes your case qualifies for an external review. By state law, your insurer must submit your request to the Division of Financial Regulation for assignment. Only the independent review organization can determine if a case qualifies for a full external review. A case qualifies for an external review if it meets at least one of the criteria below:

  1. Whether a course or plan of treatment is medically necessary.
  2. Whether a course or plan of treatment is experimental or investigational.
  3. Whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743B.225.
  4. Whether a course or plan of treatment is delivered in an appropriate health care setting and with the appropriate level of care.
  5. Whether an exception to the health plan’s prescription drug formulary should be granted.

If your case does not qualify for a full external review, the independent review organization will issue an ineligibility letter to you with an explanation as to why your case could not be reviewed.

Submitting Your Documents for Review

When your case is assigned to an independent review organization, the Division of Financial Regulation will send you, via mail, your case assignment information. This letter will detail important case time frames and the contact information for the selected independent review organization. Submit directly to the independent review organization any information you wish to be included in the review. The Division of Financial Regulation suggests you call the independent review organization directly and notify them of the additional incoming documentation.

Documentation from Your Insurer

After receiving the case documentation from your insurer the independent review organization will send you an index list of documents provided by your insurer. You may request copies of the information submitted by your insurer. Contact the independent review organization directly and request the documentation you would like to receive copies of. The independent review organization must provide you with copies of any documentation that is not confidential or privileged.

Determination

After the review has been completed the independent review organization will issue a final determination in writing. This case synopsis will include detailed information related to your case and its outcome. If you had an expedited review the independent review organization will call all parties with the case outcome and provide a final synopsis in writing.

If Your Case is Upheld

The independent review organization’s decision is binding to the insurer. If the case is upheld in the insurer’s favor you may seek legal guidance as a final option. The Division of Financial Regulation cannot provide legal advice.

If the IRO Failed to Comply with Oregon’s Statutes and Rules

The independent review organization’s decision will be final, unless within seven business days of receiving the written report the enrollee submits information to the Division of Financial Regulation stating that the independent review organization failed to comply with the requirements of Oregon statutes or rules.

The Division of Financial Regulation will review the information submitted and, within seven business days, make a written determination whether or not the independent review organization failed to comply with the procedural requirements of Oregon statutes or rules.

The term “Procedural requirements” does not include requirements related to exercising medical judgment or decision making by the independent review organization.

To submit information to the division please email: exreview.ins@oregon.gov .

Questions

If you have questions related to the external review process you may email the Division of Financial Regulation at Exreview.ins@oregon.gov

Questions or complaints?

File a complaint online or contact us:

888-877-4894 (toll-free)

Insurance
Email DFR.InsuranceHelp@oregon.gov

Financial services
Email DFR.FinancialServicesHelp@oregon.gov

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Consumer publication

Consumer Guide to Health Insurance Appeals

Consumer Guide to Health Insurance Appeals

This guide will help you understand your appeal rights in the event of a denial.

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