If we deny, stop or reduce a service your provider has ordered, we will mail you a Notice of Action/Benefit Determination letter, telling you why we made the decision.  You may ask to appeal the denial.  Follow the instructions on the Notice of Action/Benefit Determination letter to begin the appeal process.  You must file the appeal within 60 days of the date of the Notice of Action/Benefit Determination letter.   If you choose to file an appeal, health care professionals with clinical knowledge of your condition will review it.  We will mail you a Notice of Appeal Resolution letter as quickly as your health condition requires, but no longer than 16 days after the date of your request. You don’t have to file your own appeal. If you wish, an authorized (approved) representative can file an appeal for you. You can keep getting a service that was already started before our decision to deny, stop or reduce it.  You must ask to keep getting the service within 10 days of the date of the Notice of Action/Benefit Determination letter.  If the health care professional who reviews your appeal agrees that the original decision was correct, you may have to pay for the continued services you received after the date of the Notice of Action/Benefit Determination letter. If you believe that your health condition cannot wait for a regular appeal, you can ask Health Share for a fast (expedited) appeal.  You should include a statement from your provider about how your health could be harmed by waiting for the regular appeal process.  If Health Share agrees that it is urgent, we will call you with a decision in 72 hours. If Health Share does not process your appeal within 16 days or by the extended appeal timeframe, this means that the appeal process has been exhausted and you can file for an administrative hearing. You don’t have to file your own appeal. If you wish, an authorized (approved) representative can file an appeal for you.

We are committed to complying with all applicable laws, including, without limitation, Oregon’s False Claims Act and the federal False Claims Act Examples of Fraud, Waste, and Abuse.

We are all hurt by fraud, waste, and abuse in the health care system. Every dollar that is spent on fraudulent, abusive, or wasteful activities is money that can’t be spent where it is needed most.

We encourage you to report incidents of suspected fraud, waste, or abuse. Everyone has the right to report fraud, waste, and abuse anonymously and are protected under the applicable Whistleblower laws.

Health Share reports all verified cases of fraud to the Medicaid Fraud Control Unit (MCFU).

Here’s how you can report:

• Call the anonymous Health Share Compliance Hotline at 503-416-1459. 
• Call the State of Oregon Department of Human Services (DHS) Fraud Hotline: 888-372-8301. 
• Complete and return the Fraud, Waste, and Abuse reporting form.
  • You can fax the form to us at 503-459-5749 or mail it to us at:
    Compliance Officer
    Health Share of Oregon
    2121 SW Broadway, Suite 200
    Portland, OR 97201

Read about examples of Fraud, Waste, and Abuse.