HomeMy WebLinkAboutHealth Benefit Plan DocStaff Report
Date: September 24, 2012
To: Board of County Commissioners
Erik Kropp, Interim County Administrator
From: Ronda Conno
Subject: Health Benefit an Document Amendments 11 and 12
Every year, our health benefit plan is evaluated for compliance with State and Federal
regulations and cost containment methods. The Patient Protection and Affordable Care Act
(PPACA) requires all health plans to implement the mandated changes on the prescribed
schedule. Once these items are reviewed for legal compliance and approved in concept by the
Board of County Commissioners, they must be written into our health benefits plan document by
way of an amendment.
Amendment 11 to the Plan Document and Summary Plan Description for Deschutes County
Employee Benefit Plan contains the following provisions:
On July 16th, 2012 the Board voted to implement the following changes recommended by the
Employee Benefits Advisory Committee:
• Remove deductible carryover provision
• Change dental visit co -pay for non- preventive services to $25
The most significant items included in Amendment 11 as mandated by PPACA are:
• Modify Preventive Women's Health Care to match current requirements according to the
U.S. Preventive Services Task Force
• Modify the prescription Drug Benefit to match current PPACA requirements including
tobacco cessation products, folic acid, OTC contraceptives, Aspirin, Iron supplements,
and Fluoride supplements
Other changes to the Plan Document address such issues as clarifying pre -notification
requirements, clarifying ineligible services, clarifying extension of coverage for employees on
military leave an other housekeeping issues. For the detail of these changes, please refer to the
Amendment.
Amendment 12 to the Plan Document and Summary Plan Description for Deschutes County
Employee Benefit Plan contains a revised process for appeals of claim and coverage
determination. This Amendment modifies the Level II process to a written letter from the
claimant to the Plan Administrator. The Plan Administrator will make either make a
determination on the appeal if the appeal warrants it or delegate the review to an Independent
Review Organization. Level III has been modified to bind the Plan to the decision made by
either the Department of Consumer and Business Services or their designee.
Effective: August 1, 2012
r_______
REVIEWED ____ -1
COUNSEL
AMENDMENT 11 LEqGALC
L
TO THE
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION
FOR
DESCHUTES COUNTY EMPLOYEE BENEFIT PLAN
1. DELETE the following DEDUCTIBLE THREE MONTH CARRYOVER provision listed under the
MEDICAL BENEFITS section:
Deductible Three Month Carryover. Covered Charges incurred in, and applied toward the deductible in
October, November, and December will be applied toward the deductible in the next Calendar Year. Please
note that the deductible carryover provision does not apply if the deductible is satisfied.
2. AMEND the following DEDUCTIBLE/COPAYMENTS PAYABLE BY PLAN PARTICIPANTS provision
listed in SCHEDULE OF BENEFITS section as follows:
Deductibles/Copayments payable by Plan Participants
Deductibles/Copayments are dollar amounts that the Covered Person must pay before the Plan pays.
A deductible is an amount of money that is paid once a Calendar Year per Covered Person. Typically,
there is one deductible amount per Plan and it must be paid before any money is paid by the Plan for any
Covered Charges. Each January lst, a new deductible amount is required.
Deductibles do not accrue toward the 100% maximum out-of-pocket payment.
A copayment is the amount of money that is paid each time a particular service is used.
Typically, there may be copayments on some services and other services will not have any
copayments.
Copayments do not accrue toward the deductible amount. Copayments do not accrue toward the 100%
maximum out-of-pocket payment.
Deschutes County Amend 11
August 1, 2012
3. AMEND the following DENTAL COPAYMENTS listed under the DENTAL BENEFITS section in the
SCHEDULE OF BENEFITS section as follows:
DENTAL BENEFITS
Copayment
For Class A Services:
Copayment, per person, per visit $15
For Class B and C Services:
Copayment, per person, per visit $25
PLAN I - FIRST YEAR OF COVERAGE, based on a Calendar Year
Dental Percentage Payable
Class A Services - Preventive 80%, after $15 copayment
Class B Services - Basic 80%, after $25 copayment
Class C Services - Major 80%, after $25 copayment
Class D Services - Orthodontia 50%
PLAN II - SECOND/SUBSEQUENT YEARS OF COVERAGE, based on a Calendar Year
Dental Percentage Payable
Class A Services - Preventive 100%, after $15 copayment
Class B Services - Basic 100%, after $25 copayment
Class C Services - Major 100%, after $25 copayment
Class D Services - Orthodontia 50%
Deschutes County Amend 11
2 August 1, 2012
4. AMEND the following PREVENTIVE WOMEN'S HEALTH CARE benefit listed under the
PREVENTIVE CARE benefit in the SCHEDULE OF BENEFITS section as follows:
STANDARD PLAN
Preventive Care
Preventive Women's Health Care
100%, no deductible
80%, no deductible
Includes: Office visits, well -women visits, mammograms, gynecological exam, Pap smear, counseling for
sexually transmitted infections, human papillomavirus (HPV) testing, counseling and screening for human
immune -deficiency virus (HIV), interpersonal and domestic violence, contraceptive methods and counseling as
prescribed, sterilization procedures (does not include related facility charges), patient education and counseling
for all women with reproductive capacity, screening for gestational diabetes in Pregnant female Covered
Persons, breastfeeding support, supplies, and counseling in conjunction with each birth.
Preventive women's health care benefits will be subject to frequency limitations as determined by the U.S.
Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) at
http:llwww.healthcare.govicenterfregulations/preventionitaskforce.html
HIGH DEDUCTIBLE PLAN
Preventive Care
Preventive Women's Health Care
100%, no deductible 80%, no deductible
Includes: Office visits, well -women visits, mammograms, gynecological exam, Pap smear, counseling for
sexually transmitted infections, human papillomavirus (HPV) testing, counseling and screening for human
immune -deficiency virus (HIV), interpersonal and domestic violence, contraceptive methods and counseling as
prescribed, sterilization procedures (does not include related facility charges), patient education and counseling
for all women with reproductive capacity, screening for gestational diabetes in Pregnant female Covered
Persons, breastfeeding support, supplies, and counseling in conjunction with each birth.
Preventive women's health care benefits will be subject to frequency limitations as determined by the U.S.
Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) at
http://www. li ca l the arc. gov/cen terlregulati o n slprevention/tas k fore e. htm1
Deschutes County Amend 11
3 August 1, 2012
5. AMEND the following OVER THE COUNTER (OTC) MEDICATIONS provision listed under the
PRESCRIPTION DRUG BENEFITS section in the SCHEDULE OF BENEFITS section as follows:
PRESCRIPTION DRUG BENEFITS
The following will be covered at 100%, no copayment required.
(1) Physician -prescribed tobacco cessation products. Limited to a 168 -day supply per Calendar Year of
generic nicotine replacement products (nicotine patch, gum, lozenges) and a 168 -day supply per
Calendar Year of Physician -prescribed generic medications (Zyban, Chantix).
(2) Physician -prescribed folic acid for all female Covered Persons with reproductive capacity.
(3) Physician -prescribed over-the-counter (OTC) contraceptives (such as female condoms, spermicides
and sponges) for all female Covered Persons with reproductive capacity.
(4) Physician -prescribed aspirin to prevent cardiovascular disease (CVD) in adult men and women.
(5) Physician -prescribed iron supplements for asymptomatic covered Dependent children aged 6 to 12
months who are at increased risk for iron deficiency anemia.
(6) Physician prescribed fluoride supplements for covered Dependent children ages 5 years and under.
6. AMEND the following OVER THE COUNTER (OTC) MEDICATIONS provision listed in the COVERED
PRESCRIPTION DRUGS benefit provision listed under the PRESCRIPTION DRUG BENEFITS section
as follows:
PRESCRIPTION DRUG BENEFITS
Covered Prescription Drugs
The following will be covered at 100%, no copayment required.
(1)
Physician -prescribed tobacco cessation products. Limited to a 168 -day supply per Calendar Year of
generic nicotine replacement products (nicotine patch, gum, lozenges) and a 168 -day supply per
Calendar Year of Physician -prescribed generic medications (Zyban, Chantix).
(2) Physician -prescribed folic acid for all female Covered Persons with reproductive capacity.
(3) Physician -prescribed over-the-counter (OTC) contraceptives (such as female condoms, spermicides
and sponges) for all female Covered Persons with reproductive capacity.
(4) Physician -prescribed aspirin to prevent cardiovascular disease (CVD) in adult men and women.
(5) Physician -prescribed iron supplements for asymptomatic covered Dependent children aged 6 to 12
months who are at increased risk for iron deficiency anemia.
(6) Physician prescribed fluoride supplements for covered Dependent children ages 5 years and under.
Deschutes County Amend 11
4 August 1, 2012
7. AMEND the following HOSPITAL CARE provision listed in the COVERED CHARGES section under the
MEDICAL BENEFITS section as follows:
COVERED CHARGES
(1) Hospital Care. The medical services and supplies furnished by a Hospital or Ambulatory Surgical
Center or a Birthing Center. Covered Charges for room and board will be payable as shown in the
Schedule of Benefits. After 23 observation hours, a confinement will be considered an inpatient
confinement. Room charges made by a Hospital having only private rooms will be payable at the
average private room rate of that facility.
8. AMEND the following PHYSICIAN CARE benefit provision listed in the COVERED CHARGES section
under the MEDICAL BENEFITS section as follows:
COVERED CHARGES
(4) Physician Care. The professional services of a Physician for surgical or medical services.
Charges for multiple surgical procedures will be a Covered Charge subject to the following provisions:
(a) If bilateral or multiple surgical procedures are performed by one (1) surgeon, benefits will be
determined based on the Usual and Reasonable Charge that is allowed for the primary
procedures; 50% of the Usual and Reasonable Charge will be allowed for each additional
procedure performed through the same incision or during the same operative session. Any
procedure that would not be an integral part of the primary procedure or is unrelated to the
diagnosis will be considered "incidental" and no benefits will be provided for such
procedures;
(b) If multiple unrelated surgical procedures are performed by two (2) or more surgeons on
separate operative fields, benefits will be based on the Usual and Reasonable Charge for
each surgeon's primary procedure. If two (2) or more surgeons perform a procedure that is
normally performed by one (1) surgeon, benefits for all surgeons will not exceed the Usual
and Reasonable percentage allowed for that procedure; and
(c)
If an assistant surgeon is required, the assistant surgeon's covered charge will not exceed
20% of the surgeon's Usual and Reasonable allowance.
9. DELETE the following BIRTH CONTROL benefit listed under the COVERED CHARGES section under
the MEDICAL BENEFITS section:
COVERED CHARGES
(7)(e) Birth control. Injectables, implants, and devices and any related Physician charges, as described in
the Schedule of Benefits.
Deschutes County Amend 11
5 August 1, 2012
10. DELETE the following BIRTH CONTROL benefit listed under the SCHEDULE OF BENEFITS section:
STANDARD PLAN
PARTICIPATING
PROVIDERS
NON -PARTICIPATING
PROVIDERS
Birth Control
80% no deductible applies
60%, no deductible applies
HIGH DEDUCTIBLE PLAN
Birth Control
PARTICIPATING I NON -PARTICIPATING
PROVIDERS PROVIDERS
80% no deductible applies 60%, no deductible applies
11. ADD the following CONTRACEPTIVE METHODS benefit to the OTHER MEDICAL SERVICES AND
SUPPLIES provision under the COVERED CHARGES section as follows:
(7)(q1) Contraceptive methods. All Food and Drug Administration approved contraceptive methods when
prescribed by a Physician, including but not limited to intrauterine devices (IUDs) and implants,
including any related Physician charges, including insertion and removal, and will be payable under
the Preventive Women's Health Care benefit as stated under the Schedule of Benefits section.
Complications arising in connection with any contraceptive method will be payable per normal Plan
provisions.
Refer to the separate Prescription Drug Benefit of this Plan regarding prescription coverage of oral
contraceptive medications, devices, transdermals, vaginal contraceptives, implantables and injectables,
including Physician -prescribed over-the-counter (OTC) contraceptives for female Covered Persons.
12. AMEND the following benefits listed in the OTHER MEDICAL SERVICES AND SUPPLIES provision
under the COVERED CHARGES section as follows:
(7)(g) Radiation or chemotherapy and treatment with radioactive substances. The materials and services
of technicians are included.
Pre -notification of services, by the Plan Participant, for cancer treatment services is strongly
recommended. The pre -notification request to the Claims Administrator must include the Covered
Person's plan of care and treatment protocol. Pre -notification of services should occur at least 7
days prior to the initiation of treatment.
For pre -notification of services, call the Claims Administrator at the following numbers:
Toll Free in the United States: 1-800-777-3575
Local Call in Billings, Montana: 1-406-245-3575
Deschutes County Amend 11 6 August 1, 2012
A pre -notification of services by the Claims Administrator is not a determination by the Plan that
claims will be paid. All claims are subject to the provisions of the Plan, including but not limited to
medical necessity, exclusions and limitations in effect when services are provided. A pre-
notification is not required as a condition precedent to paying benefit, and can only be appealed
under the procedures in the Cost Management Services Section. A pre -notification cannot be
appealed under the Plan's Claims Review Procedures section under this Plan.
(7)(b1) Routine Preventive Care. Covered charges under Medical Benefits are payable for routine
Preventive Care as described in the Schedule of Benefits.
Charges for Routine Well Care. Routine well care is care by a Physician that is not for an
Injury or Sickness.
Charges for Women's Preventive Services as specifically stated in the Schedule of Benefits.
Charges for Routine Well Baby Care. Routine well baby care is routine care by a Physician that
is not for an Injury or Sickness.
(7)(h1) Speech therapy by a licensed speech therapist. The therapy must follow either:
(i)
Surgery for correction of a congenital condition of the oral cavity, throat or nasal complex
(other than a frenectomy) of a person;
(ii) An Injury; or
(iii) A Sickness that is other than a learning or Mental Disorder, except when rendered in
conjunction with Pervasive Developmental Disorder as stated as a benefit under this Plan.
(7)(il) Sterilization procedures for Employee and Dependent Spouse. Sterilization procedures for female
Covered Persons will be payable as shown under the Preventive Care benefit as shown in the
Schedule of Benefits.
Sterilization procedures for male Covered Persons will be payable per normal Plan provisions.
13. AMEND the following provision listed in the COORDINATED CARE provision under the COST
MANAGEMENT SERVICES section as follows:
Pre -notification of certain services is required by the Plan. Pre -notification provides information
regarding coverage before the Covered Person receives treatment, services and/or supplies. A benefit
determination on a Claim will be made only after the Claim has been submitted. A pre -notification
of services by CareLink is not a determination by the Plan that a Claim will be paid. All Claims are
subject to the terms and conditions, limitations and exclusions of the Plan at the time services are
received. A pre -notification is not required as a condition precedent to paying benefit, and can only
be appealed under the procedures in the Cost Management Services Section. A pre -notification
cannot be appealed under the Plan 's Claims Review Procedures section under this Plan.
Deschutes County Amend 11 7 August 1, 2012
14. ADD the following PRE -NOTIFICATION DETERMINATION AND REVIEW PROCESS provision to the
COST MANAGEMENT SERVICES section as follows:
PRE -NOTIFICATION DETERMINATION AND REVIEW PROCESS
The Claims Administrator, on the Plan's behalf, will review the submitted information and make a
determination on a pre -notification request within fifteen (15) days of receipt of the pre -notification
request and all supporting documentation. If additional records are necessary to process the pre-
notification request, the Claims Administrator will notify the Covered Person or the Physician. The time
for making a determination on the request will be deferred from the date that the additional information is
requested until the date that the information is received.
The Physician and Covered Person will be provided notice of the Plan's determination. In the case of an
adverse pre -notification determination, written notice will provide the reason for the adverse pre-
notification determination. If the pre -authorization request is denied, written notice will provide the
reason for the adverse pre -notification determination.
The Plan offers a one -level review procedure for adverse pre -notification determinations. The request for
reconsideration must be submitted in writing within thirty (30) days of the receipt of the adverse pre-
notification determination and include a statement as to why the Covered Person disagrees with the
adverse pre -notification determination. The Covered Person may include any additional documentation,
medical records, and/or letters from the Covered Person's treating Physician(s). The request for
reconsideration should be addressed to:
Plan Administrator
c/o Employee Benefit Management Services, Inc.
Attn: Claims Appeals
P.O. Box 21367
Billings, Montana 59104
The Plan Administrator or its designee will perform the reconsideration review. The Plan Administrator
or its designee will review the information initially received and any additional information provided by
the Covered Person, and determine if the pre -notification determination was appropriate. If the adverse
pre -notification determination was based upon the medical necessity, the Experimental/ Investigational
nature of the treatment, service or supply or an equivalent exclusion, the Plan may consult with a health
care professional who has the appropriate training and experience in the applicable field of medicine.
Written or electronic notice of the determination upon reconsideration will be provided within thirty (30)
days of the receipt of the request for reconsideration.
15. AMEND the following definitions listed in the DEFINED TERMS section as follows:
Medically or Dentally Necessary care and treatment is recommended or approved by a Physician or
Dentist; is consistent with the patient's condition or accepted standards of good medical and dental
practice; is medically proven to be effective treatment of the condition; is not performed mainly for the
convenience of the patient or provider of medical and dental services; and is the most appropriate level of
services which can be safely provided to the patient.
All of these criteria must be met; merely because a Physician recommends or approves certain care does
not mean that it is Medically Necessary.
Usual and Reasonable Charge is a charge which is not higher than the usual charge made by the
provider of the care or supply and does not exceed the general level of charges made by most providers
of like service in the same geographic area. This charge means an amount equivalent to the 90'"
percentile of a commercially available database or such other database methodologies as may be
Deschutes County Amend 11 8 August 1, 2012
available and adopted by the Plan. If there are no charges submitted for a given procedure, the Plan will
determine a Usual and Reasonable Charge based upon charges made for similar services. Determination
of the Usual and Reasonable Charge will consider the nature and severity of the condition being treated.
It will also consider medical complications or unusual circumstances that require more time, skill or
experience.
In circumstances where a network arrangement or other discounting or negotiated arrangement exists, the
Usual and Reasonable Charge means the contracted amount established by the network arrangement, or
other discounting or negotiated arrangement with a provider.
In rare instances, Hospital services (reimbursed on a Diagnostic Related Grouping (DRG), Ambulatory
Payment Classification (APC), or per diem PPO rate) can be repriced to exceed the billed amount. The
Plan will be responsible for this overage.
In no event, except as noted above, will the Usual and Reasonable Charge exceed the actual charge
billed.
The Plan Administrator has the discretionary authority to decide whether a charge is Usual and
Reasonable.
16. REMOVE the following DRG provision from the SCHEDULE OF BENEFITS section:
In rare instances, Hospital services (reimbursed on a Diagnostic Related Grouping (DRG) or per diem
PPO rate) can be repriced to exceed the billed amount. The Plan will be responsible for this overage.
17. ADD the following ineligible services to the PLAN EXCLUSIONS section as follows:
(55) Coding Guidelines. Charges for inappropriate coding in accordance with the industry standard
guidelines in effect at the time services were received.
(56) Mailing or Sales Tax. Charges for mailing, shipping, handling, conveyance, postage and sales tax.
18. AMEND the following ineligible services listed under the PLAN EXCLUSIONS section as follows:
(37) Not specified as covered. Non-traditional medical services, treatments and supplies which are not
specified as covered under this Plan.
(40) Personal comfort items. Personal comfort items, patient convenience or other equipment, such as,
but not limited to, air conditioners, air -purification units, humidifiers, electric heating units,
orthopedic mattresses, blood pressure instruments, scales, elastic bandages or stockings,
nonprescription drugs and medicines, and first-aid supplies and nonhospital adjustable beds.
Deschutes County Amend 11
9 August 1, 2012
22. DELETE the following provision listed under the WHEN RETIRED EMPLOYEE COVERAGE
TERMINATES provision listed under the TERMINATION OF COVERAGE section:
If a Retired Employee commits fraud or makes an intentional material misrepresentation in applying
for or obtaining coverage, or obtaining benefits under the Plan, then the Employer or Plan may either
void coverage for the Retired Employee for the period of time coverage was in effect, may terminate
coverage as of a date to be determined at the Plan's discretion or may immediately terminate coverage.
I, , certify that I am the
ti;�lore Title
of the Plan Sponsor/Administrator for the above named Health Plan, and further certify that I am authorized to
sign this Amendment. I have read and agree with the above change to the Plan and am hereby authorizing its
implementation as of the effective date stated above.
Signature:
Print Name:
Date:
Deschutes County Amend 11
11 August 1, 2012
AMENDMENT #12
TO THE
REVIEWED
LEGAL COUNSEL
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION
FOR
DESCHUTES COUNTY EMPLOYEE BENEFIT PLAN
Effective: August 1, 2012
1. AMEND the following GRIEVANCE PROCEDURE provision listed under the COMPLAINTS AND
GRIEVANCES provision in the CLAIMS PROCEDURES section as follows:
The Grievance procedure has three levels of review:
LEVEL I:
The Claims Administrator will evaluate all the information and make a decision. The Claims
Administrator will advise the Plan Participant in writing of its decision and the reasons for it. Some
Grievances may take longer if there are delays beyond the Plan's control. In those cases, an additional
15 days may be needed to resolve the Plan Participant's Grievance. The Claims Administrator will give
the Plan Participant or the authorized representative a notice of delay that includes a specific reason for
the delay.
Written or electronic notice of the Claims Administrator's decision will be provided to the Plan
Participant within:
• 30 days of receipt of a Grievance for a Post -Service Claim;
• 15 days of receipt of a Grievance for a Pre -Service Claim or a Concurrent Care Claim; or
• 72 hours of receipt of a Grievance for an Urgent Care Claim.
Except for Grievances concerning Urgent Care Claims, if the Plan Participant is not satisfied with the
outcome at Level I, the Plan Participant may request a review at Level II:
• If regarding a Post -Service Claim, 180 days of the date the Plan Participant is notified of the
outcome of the Level I review;
• If regarding a Pre -Service Claim, 30 days of the date the Plan Participant is notified of the outcome
of the Level I review; or
• If regarding a Concurrent Care Claim, 15 days of the date the Plan Participant is notified of the
outcome of the Level I review.
If regarding an Urgent Care Claim, the Plan Participant must file a Grievance at Level III. Urgent Care
Claims shall not be grieved at Level II.
Deschutes County Amend 12 1 August 1, 2012
LEVEL II:
The Grievance will be reviewed by the Plan Administrator. The Plan Administrator may elect to
delegate this review to the Claims Administrator or an independent external review organization chosen
by the Plan Administrator. The Plan Participant should provide the Plan Administrator with any
additional information not previously reviewed to support the Grievance. Such additional information
should be provided with the Grievance or as soon after the Grievance is submitted as possible, but in no
event later than 20 days after submission of the Grievance.
A Plan Participant may also provide a written statement to the Plan Administrator explaining why the
Grievance should be resolved as requested by the Plan Participant. The written statement must be
provided no later than 20 days after submission of the Grievance at Level II. Any written statement
provided by the Plan Participant will be reviewed and considered by the Plan Administrator in deciding
the Grievance.
If the Plan Administrator has elected to delegate review of the Grievance to an independent review
organization, the written statement will be provided to the independent review organization for review
and consideration. In the event a Plan Participant fails to timely provide additional information or a
written statement in support of the Grievance, the additional information or written statement will not be
considered. The Plan Administrator's decision regarding the Grievance shall be based on (1) the
findings and conclusions of a delegated external review, if any, and (2) the express terms and conditions
of the Plan Document. Written or electronic notice of the Plan Administrator's decision will be
provided to the Plan Participant within:
• 30 days of receipt of a Grievance for a Post Service Claim;
• 15 days of receipt of a Grievance for a Pre -Service Claim or a Concurrent Care Claim; or
If the Plan Participant is not satisfied with the outcome of the Level II review, he or she may request a third
and final external review through Level III.
LEVEL III:
This Plan has an external review program that meets the requirements of ORS 743.857(1)(a)(b) or (c), ORS
743.859(1)(2) or (3), and ORS 743.861(1), External reviews will be provided through an independent review
organization that is under contract with the Oregon Director of the Department of Consumer and Business
Services.
A Plan Participant may, by written application to the Plan, obtain review by an independent review
organization for a Level III Grievance on one or more of the following:
• Whether a course or plan of treatment is Medically Necessary.
• Whether a course or plan of treatment is Experimental or Investigational.
• Whether a course or plan of treatment that an Plan Participant is undergoing is an active course of
treatment for purposes of continuity of care under ORS 743.854.
A Plan Participant shall apply in writing for external review of an adverse decision by the Plan not later than
180 days after receipt of the Plan's final written decision following Steps I and II of this Grievance procedure.
A Plan Participant is eligible for external review only if the following requirements have been met:
Deschutes County Amend 12 2 August 1, 2012
• The Plan Participant must have signed a waiver granting the independent review organization access
to the medical records of the Plan Participant.
• The Plan Participant must have exhausted all review rights through Level I and Level II of the
Plan's Grievance procedure before submitting a request for a Level III external review. The Plan
may waive the requirement of compliance with the internal Grievance procedure and have a dispute
referred directly to external review upon the Plan Participant's written consent.
• The Plan Participant must provide accurate and complete information to the independent review
organization in a timely manner.
The Plan agrees to be bound by the results of the Level III external review.
Other assistance may be available from the Oregon Insurance Division:
By Calling: (503) 947-7984
By Writing: Director of the Department of Consumer and Business Services Consumer
Protection Unit, 350 Winter Street, N.E., Room 440-2, Salem, OR 97310
On the Internet at: http://www.cbs.state.or.us/external/ins
I, . certify that I am the
Nam 1:11e
of the Plan Sponsor/Administrator for the above named Health Plan, and further certify that I am authorized
to sign this Amendment. I have read and agree with the above change to the Plan and am hereby authorizing
its implementation as of the effective date stated above.
Signature:
Print Name:
Date:
Deschutes County Amend 12 3 August 1, 2012