1. (1) An insurer must acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal.
2. (2)An insurer must make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

3. (3) An otherwise applicable standard for timeliness in sections (1) or (2) of this rule does not apply when:

   1. (a) The period of time is too long to accommodate the clinical urgency of the situation;
   2. (b) The enrollee does not reasonably cooperate; or
   3. (c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise.
4. (4) For adverse benefit determinations eligible for external review under ORS 743.857, an insurer may waive its internal appeals process at any time. If the insurer waives its internal appeals process, the internal appeals process is deemed exhausted for the purposes of qualifying for external review.

Statutory/Other Authority

ORS 731.244

Statutes/Other Implemented

ORS 743.804

History

ID 12-2013, f. 12-31-13, cert. ef. 1-1-14
ID 23-2011, f. & cert. ef. 12-19-11
ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11
ID 5-2000, f. & cert. ef. 5-11-00
ID 1-1998, f. & cert. ef. 1-15-98