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2008 OHP managed care contracts
(Files are in PDF format)
2008 Fully Capitated Health Plans (FCHPs) 2008 FCHP contract for OHP Plus and OHP Standard
2008 Dental Care Organizations (DCOs) 2008 DCO contract
2008 Chemical Dependency Organizations (CDOs) 2008 CDO contract
2008 Physician Care Organizations (PCOs) 2008 PCO contract
Frequently Asked Questions About Complaints and Appeals
FCHP, DCO, CDO and PCO contractors are required to send out a denial letter (called Notice of Action) to DMAP clients for the denial of an action, as defined in OAR 410-141-0260, which includes the denial of payment for services.
Q: Can a client ask for an appeal regarding the denial of payment for services already rendered? A: A client is entitled to an appeal of the decision to deny payment of a claim. If the denial is upheld at appeal, the managed care plan must issue a Notice of Appeal Resolution with the client’s right to request a hearing. If the client files a request for hearing, DMAP will determine whether or not the issue is hearable. This depends on whether or not the client is being billed for the services. If the client is being billed for the services, the provider must have a valid waiver required by OAR 410-120-1280. If the client is not being billed for the services, the issue is between the provider and the managed care plan.
Q: Can a provider appeal a decision regarding the denial of payment for services? A: A provider can appeal the decision through the managed care plan and then, if not resolved through this process, may ask for an administrative review by DMAP in accordance with OAR 410-120-1560 through 410-120-1720.
Q: Can a provider represent a client in an appeal with the managed care plan regarding the denial of payment for services? A: Anyone the client so designates can represent the client in an appeal or hearing regarding the denial of payment for services. The client must provide written consent.
This page was last updated Feb. 2008 |
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