OHP/Medicaid

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Appeals, Grievances, and Complaints

Please see the FamilyCare Health OHP Member Handbook for more information about the Medicaid Appeals & Grievances process. Medicare appeals and grievances information may be accessed on the Medicare Portal Complaints Page. FamilyCare Health will provide reasonable assistance with completing forms or other reasonable steps to completing forms and providing interpretation services and TTY/TTD services. 

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Grievances

A complaint or dispute expressing dissatisfaction with healthcare services or a provider of the health plan. It can include concerns about the operations such as: wait times, the attitude of personnel, the condition of facilities, the respect given to members, or the services provided. Grievances can only be filed by Members or Members' Representatives* 

*In order to appoint a representative to submit a complaint or problem on their behalf, the member and their representative may complete form CMS-1696 (or a written equivalent) and submit to us at the address below. 

Write to: FamilyCare Health Plan
Navigation Services
825 NE Multnomah, Suite 1400
Portland, OR 97232

FamilyCare Health responds to grievances as fast as the Member’s health condition requires but no later than the regulatory timeframes:

Medicaid Grievance
Standard: 5 calendar days**
Expedited: 1 calendar day

** An extension allows us up to 30 days

Medicaid DHS/OHA complaint forms (OHP 3001) are available on the OHA website forms page.

Retaliation for utilizing the grievance system process will not be accepted. No member or their representative will be discouraged from using any aspect of the grievance process or encouraged to withdraw a grievance request already filed.

Appeals

A request for the review of FamilyCare Health's decision to refuse to provide services or drugs that the member, their provider, or the member’s representative believes the member is entitled to receive. 

The appeal process involves FamilyCare Health reviewing the original decision made, the findings upon which it was based, and any other evidence submitted or obtained. An appeal can be filed by the Member, their Representative*, or Provider with member’s consent. 

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Appeals must be filed within the regulatory timeframes unless there is a good cause for missing the deadline.

Medicaid appeals timeframe: Request must be received orally or in writing within 45 days of notification of an adverse decision. Oral filings need to have a written, signed, and dated appeal letter to be completed. 

To file an appeal on behalf of a member, providers must have member consent and contact us:

Write to: FamilyCare Health Plan
Appeals & Grievances
825 NE Multnomah, Suite 1400
Portland, OR 97232
Phone: 503-471-2117
Fax: 503-471-2167

For Claim Reconsiderations, please see our Claims FAQ.

Medicaid DHS/OHA appeal forms (OHP 3302) are available on the OHA website forms page.

FamilyCare Health responds to appeals as expeditiously as the Member’s health condition requires but no later than the regulatory timeframes:

Medicaid Appeals
Standard: 16 calendar days
Expedited: 3 working days

An extension of 14 calendar days is allowed for all appeals. 

Hearings - Medicaid

FamilyCare Health informs members, both orally and in writing, about their appeal and hearing rights with the notice of action, during phone conversations when there is an expression of dissatisfaction with an action, and in the member handbook. Members are not required to go through FamilyCare Health to file an appeal or hearing. 

If the appeal was referred from OHA as part of a contested case hearing process, the member may request a hearing no later than 45 calendar days from the date on the Notice of Appeal Resolution. 

If the appeal was referred by OHA within two business days from the date of the appeal resolution, FamilyCare Health will transmit the Notice of Appeal Resolution and the complete record of the appeal to the Division’s Hearings Unit. 

The member, their representatives or subcontractors/providers, with written consent from the member, may challenge the denial of coverage of, or payment for, medical assistance and file an appeal either with FamilyCare Health, their provider or OHA.

DHS/OHA Administrating Hearing Request forms (MSC 443), Notice of Hearing Rights forms (OHP 3030) are available on the OHA website forms page.

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