State guide
Oregon
Pick the kind of plan you have to see who to call first. Oregon can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Oregon usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Oregon Division of Financial Regulation. See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Oregon.
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Medicare
Senior Health Insurance Benefits Assistance (SHIBA) gives free counseling. Or call 1-800-MEDICARE.
The short version for Oregon
In Oregon you ask your insurer for an external review and the Division of Financial Regulation randomly assigns an independent reviewer; the insurer must pay and cannot charge you. Oregon is one of the few states that publishes past external review decisions and yearly results (about a third of reviewed denials are overturned). The Division's consumer advocates give free help, and Oregon Health Plan members have a separate ombuds program.
At a glance: independent review for plans Oregon regulates
- Main regulator
- Oregon Division of Financial Regulation · 888-877-4894
- Independent review
- A state process (External review)
- Deadline to request it
- 180 calendar days after you receive the final adverse benefit determination letter
- Cost
- None. State law bars insurers from charging enrollees a fee for external review.
- Decision time
- 30 calendar days; fast track: 3 calendar days
Who regulates health plans
- Oregon Division of Financial Regulation
Health insurance bought by individuals and coverage that employers buy from an insurance company doing business in Oregon.
Phone: 888-877-4894. File a complaint online
Independent (external) review
- Process
- A state process. Run by Oregon Division of Financial Regulation, which randomly assigns a contracted independent review organization.
- Where you file
- insurer
- How
- Send a written request for external review to your health plan, which must pass it to the Division of Financial Regulation for assignment. For an expedited review, add a letter and supporting documents from your provider saying the normal time would jeopardize your life or health. Questions: 888-877-4894 or exreview.ins@dcbs.oregon.gov.
- Which denials qualify
- Disputes about whether treatment is medically necessary, whether it is experimental or investigational, whether you are in an active course of treatment for continuity of care, whether care is in the appropriate setting and level of care, and whether an exception to the plan's drug list should be granted.
- Appeal to the plan first?
- Yes, unless you and the insurer both agree to go directly to external review.
- Published results
- In 2024 the Division received 555 external review cases; 415 got a full review, and the insurer's denial was overturned or partly overturned in 34% of those. The rate was 36% in 2023 and 37% in 2022. Source
Free help in Oregon
- Oregon Division of Financial Regulation consumer advocates
Explain the appeal process for state-regulated health insurance and take complaints against insurers; email DFR.InsuranceHelp@dcbs.oregon.gov.
Phone: 888-877-4894
- Oregon Health Authority Ombuds Program
Advocates for Oregon Health Plan (Medicaid) members who have concerns about getting care; staff aim to respond within 5 working days.
Phone: 1-877-642-0450 (message line only)
Medicare and Medicaid in Oregon
- Medicare counseling
- Senior Health Insurance Benefits Assistance (SHIBA) · 800-722-4134 . Free help with Medicare appeals.
- Medicaid agency
- Oregon Health Authority, Oregon Health Plan
- Fair hearing deadline
- 120 calendar days from the date on the Notice of Appeal Resolution from your coordinated care organization, or 60 calendar days from the date on a Notice of Denial issued by the Oregon Health Authority. Your notice states the deadline that applies to you.
- Good to know
- Members of a coordinated care organization (the Oregon Health Plan's managed care plans) must appeal to the organization first, within 60 days of the date on the denial notice, before asking for a hearing. Hearing questions: 503-945-5785.
State laws that can help
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Step therapy. Plans must approve a step therapy exception in listed situations, such as when the required drug is likely to be ineffective or cause harm, and must decide within 72 hours or two business days, whichever is later (one business day in urgent cases), or the request is treated as granted.
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Prior authorization. Insurers must answer a non-emergency prior authorization request within two business days, and an approval generally stays binding for at least 60 days after treatment begins, or one year for maintenance drugs that meet set conditions.
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Surprise billing. Out-of-network providers cannot bill you beyond your plan's cost sharing for emergency care or for services at an in-network facility, unless you knowingly chose an out-of-network provider for non-emergency care.
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External review. Insurers must pay all costs of external review and cannot charge enrollees, and the reviewer may reverse a denial if the insurer fails to hand over records on time.
Sources and what we could not confirm
- If your claim was denied (Oregon Division of Financial Regulation)
- IRO Case Detail Report (Oregon Division of Financial Regulation)
- File a complaint (Oregon Division of Financial Regulation)
- Consumer Guide to Health Insurance Appeals (Oregon Division of Financial Regulation)
- Appeals and Hearings (Oregon Health Authority)
- Ombuds Program (Oregon Health Authority)
- Medicare help (Oregon SHIBA)
- Oregon Consumer Assistance (Centers for Medicare & Medicaid Services)
- State External Appeals Review Processes (Centers for Medicare & Medicaid Services)
Not confirmed (7)
- How to tell whether the state regulates your plan. no Division of Financial Regulation page read explains how to tell a self-insured plan from a state-regulated one
- The independent review request form. no request form found; the Division asks for a written request to the insurer
- Where to file for independent review. consumer pages say to file with the insurer; the statute text also mentions applying to the director
- A searchable list of past decisions. the report is a downloadable spreadsheet covering a rolling four years, not an online search
- Free consumer help programs. the federal directory says Oregon's Consumer Assistance Program grant has ended and mentions Oregon Health Connect at 1-866-698-6155; that program was not confirmed and is not listed
- Notes on Medicaid appeals. the deadline to keep benefits during an appeal was not confirmed
- State laws that help. statute text was read on oregon.public.law, an unofficial copy, not on the Oregon Legislature site