Oregon Statutes 743B.255 – 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 insurer’s final written decision following its grievance and internal appeal process under ORS § 743B.250.
Terms Used In Oregon Statutes 743B.255
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
(2) An enrollee is eligible for external review only if the enrollee has exhausted the plan’s internal appeal procedures established pursuant to ORS § 743B.250 or be deemed to have exhausted the plan’s 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 enrollee’s consent. An enrollee is deemed to have exhausted the internal appeal procedures if the insurer fails to strictly comply with ORS § 743B.250 and federal requirements for internal appeals.
(3) 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 § 743B.252. [Formerly 743.861; 2021 c.205 § 10]