Dispute Resolution
DISPUTE RESOLUTION PROCEDURES
Dispute resolution includes the resolution of disputes arising under peer review, service utilization review, and quality assurance activities between insurers, self-insured employers, injured workers, and medical and health care service providers, as required under the certified plan (ORS 656.260 (4)(d)(E)).
Disputes or complaints arising from decisions made in the service utilization review process or quality assurance process must be made in writing within thirty (30) days of the action giving rise to the dispute. The dispute or complaint should include any additional information the party wishes to have considered in the review by OHS and be directed to:
Medical Director
Oregon Health Systems, Inc.
P.O. Box 3810
Tualatin, OR 97062-3810
1-800-525-0394
Disputes or complaints about administrative issues or concerns should be directed in writing to the OHS Administrator at the address listed above within 30 days of the date of the action giving rise to the dispute. Administrative issues or concerns will be reviewed by the OHS Administrative Review Committee.
OHS will notify all parties in writing when a dispute is received. Absent a showing of good cause, failure to appeal within 30 days of the action giving rise to the dispute shall preclude further appeal to the Director of the Department of Consumer and Business Services.
When a medical dispute arises, it is referred by the OHS Medical Director to the Medical Review Committee (MRC). This Committee is comprised of physicians appointed by OHS, with appropriate expertise and specialties to review the treatment issue(s) in dispute. The Committee will review the medical treatment issue and make a determination whether to uphold the decision, obtain additional information, or reverse the decision. Any time additional medical information is required or obtained through the dispute resolution process, it will be reviewed by the OHS Medical Director and/or the MRC and either the dispute will be resolved or will move through the process as described above. If the MRC determines an actual patient evaluation is required to determine the outcome of the dispute, successful completion of the dispute resolution process is predicated on the injured worker participating in the suggested evaluation. If the injured worker refuses to participate in an evaluation recommended by the MRC to make a determination in the dispute, the initial decision made by the MCO will be upheld.
The dispute resolution process will be completed within 60 days of the date that OHS receives written notice of a dispute. At the completion of the dispute resolution process, OHS will notify all parties of the decision in writing. Such notice will include an explanation of the reasons for the decision, as well as the right to seek administrative review by the Director of the Department of Consumer and Business Services.
If the dispute was appealed in a timely manner and cannot be resolved to the satisfaction of the referring party through the OHS dispute resolution process, the aggrieved party may request administrative review from the Director of the Department of Consumer and Business Services, pursuant to OAR 436-015-0008 within 60 days. Failure to appeal the decision to DCBS within 60 days will preclude further appeal.
Any dispute relating to Contract Review must be appealed to Oregon Health Systems within fourteen (14) days of the action giving rise to the dispute. There is no appeal through the Oregon Health Systems Dispute Resolution process for the ÒElection of PartyÓ clause in the OHS Provider Agreement, where either party may elect to terminate the Agreement with ninety (90) days notice to the other party.
Appeals relating to Contract Review issues outside of the "Election of Party" clause will be heard by the OHS Administrative Review Committee. OHS will complete the Contract Review process within sixty days of the receipt of the appeal and notify the appealing party of its decision. Failure to appeal a Contract Review issue within 14 days of the action giving rise to the dispute will preclude further appeal to the Department of Consumer and Business Services.