How to appeal a health insurance denial in Oregon
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Oregon lets you ask an independent reviewer to decide, through Oregon Division of Financial Regulation (Department of Consumer and Business Services). The deadline to ask: 180 calendar days after receiving your final adverse benefit determination letter.
Does this apply to you? State external review covers plans regulated by Oregon: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Oregon
180 calendar days after receiving your final adverse benefit determination letter
An expedited review is completed within 3 calendar days (72 hours). You need a letter from your provider, with supporting documentation, saying the normal timeline would jeopardize your life, health or ability to regain maximum function; you can request expedited internal and expedited external review at the same time.
Free (by law the insurer pays and may not charge enrollees a fee)
State-regulated plans (insurance bought in Oregon or through an employer that buys insurance). Self-funded employer plans use the federal process.
Send a written request to your insurer with a signed HIPAA release for your medical records; the insurer must forward it to DFR, which randomly assigns an IRO (state law also allows applying to DFR directly). 888-877-4894 is toll-free in Oregon; the Salem line is 503-378-4140, and external review questions can go to Exreview.ins@dcbs.oregon.gov.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Oregon?
180 calendar days after receiving your final adverse benefit determination letter
Can I get a fast external review in Oregon?
An expedited review is completed within 3 calendar days (72 hours). You need a letter from your provider, with supporting documentation, saying the normal timeline would jeopardize your life, health or ability to regain maximum function; you can request expedited internal and expedited external review at the same time.
Does external review cost anything in Oregon?
Free (by law the insurer pays and may not charge enrollees a fee)
Do Oregon’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Oregon DFR - If your claim was denied
You have 180 calendar days after receiving your final adverse benefit determination letter to submit your request for an external review.
- ORS 743B.255
not later than the 180th day after receipt of the insurer’s final written decision
- ORS 743B.252
The insurer may not establish or charge a fee payable by enrollees for conducting external review.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.