Government Contract | Oregon
External Review

Bid Information

Bid Alert No: 00000453771

Bid Title: External Review

Agency Bid No. Title: DCBS-1462-15

Received Date: 01/06/2016

Close Date: 01/15/2016

Purchase Type: Not Stated

Delivery Point: Oregon

Delivery Date: Not Stated

Special Notices: Bidder Preregistration


Specifications include, but are not limited to:Insurers offering comprehensive, fully-insured health benefit plans in Oregon mustallow enrollees to appeal denials of coverage to independent review organizations(IROs). IRO's are independent of the insurers. They review medical records and otherrelevant materials to determine if the insurer made the correct decision.During external review, an enrollee in a health plan may ask an insurer for anindependent external review of an adverse decision by the insurer when the decisionconcerns whether a plan of treatment is: Medically necessary Experimental or investigational An active course of treatment for purposes of obtaining continuity of careunder ORS 743.854. Appropriate health care setting and level of care.An enrollee applies for an external review directly with their health insurer. A requestfor external review must be made no later than one hundred eighty (180) days afterthe date that the enrollee has received the insurer's final written decision followingits internal grievance and appeal process. Enrollees are eligible for external reviewonly after exhausting the health plan's internal grievance procedures, unless theinsurer and enrollee agree to go directly to external review. An enrollee is deemed tohave exhausted the internal appeal procedures if the insurer fails to strictly complywith legal requirements for internal appeals. See ORS 743.861(1).After an enrollee requests external review, the insurer submits a request to DCBSInsurance Division. External reviews are randomly assigned to one of the IRO's with anapproved contract. See OAR 836-053-1340(3).The IRO first determines if the dispute qualifies for external review. If so, the disputeis reviewed and a written decision based on expert medical judgment is issued. The

Product Codes: 91869, 91878

Agency Information

Issuing Agency: State of Oregon Department of Consumer and Business Services

State: Oregon

Agency Type: State and Local

Contact: Robin Linville 350 Winter St. NE, Room 11, Salem, Oregon, 97309

Phone: 503-947-7926

Fax: 503-947-7085




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