We know it can be confusing sometimes to know where to start when it comes to certain health care and health plan activities. Here, we’ve gathered some common tasks and explain how to go about addressing them. If you still have questions or need help, please contact us.
You can have this document in another language, large print, Braille, CD, on tape, or another format, please contact us. Here is the Member Handbook if you would like to read or print it. If you want us to send you a Member Handbook, please contact us.
You can have a free voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider’s office that you need an interpreter and for which language. Information on Health Care Interpreters is at www.Oregon.gov/oha/oei.
You can have a copy of your medical records. Your Primary Care Physician and Primary Care Dentist have most of your records, so you can ask them for a copy.
They may charge a reasonable fee for copies. You have the right to request changes or corrections to your medical records. You can ask us for a copy of the records we have. We will not charge you a fee for the copies.
You can have a copy of your mental health records unless your provider thinks this could cause serious problems.
Call your Primary Care Provider (PCP), Primary Care Dentist (PCD) or mental health provider. See information in the following sections about getting a PCP, PCD or mental health provider if you do not already have one.
Here are some helpful tips when making an appointment with your PCP, PCD, Dental Plan and Mental Health providers:
What to take with you:
If you are very unhappy with IHN-CCO, your health care services or your provider, you can complain or file a grievance. We will try to make things better.
Just call us or send us a letter. We will call or write back in a week to let you know that we are working on it.
We will send you a letter in 30 days explaining how we will address your complaint. We will not tell anyone about your complaint unless you ask us to. You can also complain to the Oregon Health Authority. Call Client Services at 1-800-273-0557 (TTY 711), or send your complaint to:
Oregon Health Plan Client Services
P.O. Box 14520
Salem, Oregon 97309
If we deny, stop or reduce a medical, dental, or mental health service your provider has ordered, we will mail you a Notice of Action letter explaining why we made that decision. You have a right to ask to change it through an appeal, a state fair hearing, or both. You must ask no more than 45 days from the date on the Notice of Action letter.
You may ask for an appeal by:
If you want help with this, call and we can fill out an appeal form for you to sign. You can ask someone like a friend or case manager to help you. You may also call the Public Benefits Hotline at 1-800-520-5292 for legal advice and help. You will get a Notice of Appeal Resolution from us in 16 days letting you know if the reviewer agrees or disagrees with our decision. If we need more time to do a review, we will send you a letter saying why we need up to 14 more days.
You can keep on getting a service that already started before our decision to stop it. You must ask us to continue the service within 10 days of getting the Notice of Action letter that stopped it. If you continue the service and the reviewer agrees with the original decision, you may have to pay the cost of the services that you received after the Effective Date on the Notice of Action letter.
If you and your provider believe that you have an urgent medical, dental, or mental health problem that cannot wait for a regular appeal, tell us that you need a fast (expedited) appeal. We suggest that you include a statement from your provider or ask them to call us and explain why it is urgent. If we agree that it is urgent we will call you with a decision in 3 workdays.
Your provider has a right to appeal for you when their physician’s orders are denied by a CCO. You must give your provider written consent to appeal for you.
You can have a state fair hearing with an Oregon Administrative Law Judge. You will have 45 days from the date on your Notice of Action or Notice of Appeal Resolution to ask the state for a hearing. Your Notice of Action letter will have an Appeal and Hearing Request form that you can send in. You can also ask us to send you an Appeal and Hearing Request form, or call OHP Client Services at 800-273-0557, TTY 711, and ask for form number 3302.
At the hearing, you can tell the judge why you do not agree with our decision and why the services should be covered. You do not need a lawyer, but you can have one or someone else, like your doctor, with you. If you hire a lawyer you must pay their fees. You can ask the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 800-520-5292, TTY 711, for advice and possible representation. Information on free Legal Aid can also be found at www.oregonlawhelp.org.
A hearing often takes more than 30 days to prepare. While you wait for your hearing, you can keep on getting a service that already started before our original decision to stop it. You must ask us to continue the service within 10 days of getting the Notice of Action that stopped it. If you continue the service and the judge agrees with the original decision, you may have to pay the cost of the services that you received after the Effective Date on the original Notice of Action.
If you and your provider believe that you have an urgent medical, dental, or mental health problem that cannot wait for a regular hearing process, say that you need a fast (expedited) hearing and fax the Hearing Request form to the OHP Hearings Unit. We suggest that you include a statement from your provider explaining why it is urgent. You should get a decision in 3 workdays. The Hearings Unit’s fax number is 503-945-6035.