Compliance Corner
In Oregon, if an MCO receives a complaint or dispute that is not included in the MCO dispute resolution process, the MCO must, within seven days from the date of receiving the complaint, notify the parties in writing of their right to request review by the director under OAR 436-015-0008.
As Simply Research subscribers know, the notice must include the following in bold text and be formatted as follows:
Notice to the worker and all other parties:
If you want to appeal this decision, you must:
– Notify us in writing within 30 days of the mailing date of this notice
– Send your written request for review to:
{MCO name}
{MCO address}
If you have questions, contact {MCO contact person and phone number}. If you do not notify us in writing within 30 days, you will lose all rights to appeal the decision, unless you show good cause. If you appeal within the 30-day timeframe, we will review the disputed decision and notify you of our final decision within 60 days of your request. After that, if you still disagree with our decision, you may appeal to the Department of Consumer and Business Services (DCBS) for further review. If you do not seek dispute resolution through us, you will lose your right to appeal to DCBS
If an MCO receives a complaint or dispute that is not included in the MCO dispute resolution process, the MCO must, within seven days from the date of receiving the complaint, notify the parties in writing of their right to request review by the director under OAR 436-015-0008.
The notice must include the following in bold text and be formatted as follows:
Notice to the worker and all other parties:
{MCO name} does not have a process to review the type of issue you have raised. To pursue this issue you must request administrative review by the Department of Consumer and Business Services (DCBS) within 60 days of the mailing date of this notice.
If you do not notify DCBS in writing within 60 days, you will lose all rights to appeal the decision.
Send your written request for review to:
DCBS Workers’ Compensation Division
Medical Resolution Team
350 Winter Street NE
PO Box 14480
Salem OR 97309-0405
For help, call the Workers’ Compensation Division’s toll-free hotline at 800-452- 0288 and ask to speak with a benefit consultant.
