2013 ORS § 743.861¹
Enrollee application for external review
  • when enrollee deemed to have exhausted internal appeal

(1) An enrollee shall apply in writing for external review of an adverse benefit determination by the insurer of a health benefit plan not later than the 180th day after receipt of the insurers final written decision following its grievance and internal appeal process under ORS 743.804 (Required notices to applicants and enrollees). An enrollee is eligible for external review only if the enrollee has satisfied the following requirements:

(a) The enrollee must have signed a waiver granting the independent review organization access to the medical records of the enrollee.

(b) The enrollee must have exhausted the plans internal appeal procedures established pursuant to ORS 743.804 (Required notices to applicants and enrollees) or be deemed to have exhausted the plans internal appeal procedures. The insurer may waive the requirement of compliance with the internal appeal procedures and have a dispute referred directly to external review upon the enrollees consent. An enrollee is deemed to have exhausted the internal appeal procedures if the insurer fails to strictly comply with ORS 743.804 (Required notices to applicants and enrollees) and federal requirements for internal appeals.

(2) An enrollee who applies for external review of an adverse benefit determination shall provide complete and accurate information to the independent review organization as provided in ORS 743.857 (External review). [2001 c.266 §11; 2011 c.500 §33]