Oregon Medicaid Appeals and Fair Hearings: How to File

If your Oregon Health Plan coverage was denied, reduced, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided.1 The Oregon Health Plan (OHP) is Oregon's Medicaid program, and most members receive care through a coordinated care organization (CCO), which changes where you file first.

In This Guide

• What can you appeal in Oregon Medicaid?
• Oregon Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal
• How coordinated care organization (CCO) appeals work
• How to request a fair hearing in Oregon
• Frequently Asked Questions

What can you appeal in Oregon Medicaid?

Federal law gives Medicaid applicants and members a right to a fair hearing before the state agency when a claim for medical assistance is denied or not acted on with reasonable promptness, or when they believe the agency acted erroneously. The one case the federal rule carves out is a change that flows automatically from a federal or state law affecting some or all beneficiaries, where the agency need not grant a hearing.1 In Oregon, that right runs through the Oregon Health Plan, and a denial arrives as a written Notice of Adverse Benefit Determination (also called a Notice of Denial) issued by either your coordinated care organization or the Oregon Health Authority.2

Under the federal managed care rules at 42 CFR 438.404, a plan must give you that notice in writing, and the rule sets a deadline for each kind of decision: ending, suspending, or reducing a service it had already approved, denying payment, denying a request to authorize a service, and failing to decide in time.3 In practice, you can appeal:

• A denial of an OHP application or of a specific covered service
• A prior authorization denial
• A reduction in an approved service, such as a cut to in-home care hours
• A termination or suspension of a service you were already receiving
• A denial of payment for care you have already received

The right reaches across the program, not just applications. If the state or your plan took an action against your coverage or your care, a notice should have told you so, and that notice is what starts the appeal clock.

Oregon Medicaid appeal deadlines that decide your case

In Oregon, the appeal deadlines depend on whether your care runs through a coordinated care organization or directly through the state, and they are not the same figure. Each one runs from the date printed on your notice.

If a coordinated care organization issued your Notice of Adverse Benefit Determination, the plan must receive your appeal within 60 days of the date on that notice.2 This is the required first step, and the federal managed care rule sets the same 60-day filing window.4

After the coordinated care organization issues its Notice of Appeal Resolution upholding the denial, you have 120 days from the date on that resolution to ask the Oregon Health Authority for an administrative hearing, also called a contested case hearing.2 Federal law requires the state to allow no fewer than 90 and no more than 120 days from the plan's notice of resolution, and Oregon sets its window at the 120-day maximum.2 The general fair hearing request runs on a different rule: federal law caps it at 90 days from the date a notice is mailed, and that 90 days is the most a state may allow rather than a minimum you are owed, so a shorter deadline set by the state binds you.5

A third deadline, the 10-day window to keep your benefits flowing during the appeal, is shorter than both of these and is covered in the next section.

Read the date and the deadline off your own notice. If your notice came directly from the Oregon Health Authority under fee-for-service (Medicaid billed per service rather than through a plan), you ask the Oregon Health Authority for a hearing without the coordinated care organization appeal step, and you send the completed hearing request within 60 calendar days of the date on its Notice of Denial.2 That is half the 120 days a coordinated care organization member gets after a plan appeal, and it sits inside the federal ceiling of 90 days from the date a notice is mailed.5 Go by the deadline printed on your own notice, and file well inside it.

How to keep your benefits during the appeal

Under federal law, if the agency sent the required advance notice and you request the hearing before the date the action takes effect, the agency may not terminate or reduce the service until a decision is rendered after the hearing, unless both halves of a narrow exception are met: the hearing determines that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that the service will be terminated or reduced pending the decision.6 Oregon calls this continuing your benefits, and lawyers call it aid paid pending.

If the notice is about a service you already get, you may be able to keep getting it only if you ask your coordinated care organization or the Oregon Health Authority to continue it when you file your appeal or hearing request, and do so within 10 days of the effective date on the notice. If the notice reached you after its effective date, the Oregon Health Authority says to call your plan or the Authority for instructions rather than treat the window as closed.2 The request is not automatic. You have to ask for it, and asking after that 10-day window closes can mean your services stop while the appeal is decided.

Continuing your benefits carries one consequence worth knowing before you ask. If the decision goes against you, federal law lets the agency recover the cost of the services that were furnished solely because you asked for the continuation. It does not let the agency bill you for everything you received while the appeal was pending.6 The Oregon Health Authority puts it this way: if the reviewer agrees with the original decision, you may have to pay for services you received after the effective date on the notice.2 Your plan's notice is required to spell out the circumstances under which you may be asked to pay those costs.3 For most families the protection is still worth having, but ask with that in view.

If you and your provider believe the problem is urgent and cannot wait, you can ask for a fast (expedited) review, but it is not automatic. For a plan appeal, tell your coordinated care organization you need an expedited appeal and include a statement from your provider; if the plan agrees it is urgent, a staff member calls you with the decision in 72 hours. For a hearing, if the Oregon Health Authority agrees it is urgent, its Hearings Unit calls you in 72 hours.2

The practical takeaway: when any Notice of Adverse Benefit Determination arrives, find the effective date on it, file your appeal or hearing request before that date, and ask to continue your benefits at the same time.

How coordinated care organization (CCO) appeals work

Most OHP members get their care through a coordinated care organization (CCO), Oregon's name for its Medicaid managed care plans, and a CCO member must first appeal to the plan, then ask the Oregon Health Authority for a hearing if they disagree with the plan's decision.2

The plan appeal comes first. Your coordinated care organization must receive your appeal within 60 days of the date on the Notice of Adverse Benefit Determination.2 The plan then has 16 days to review its decision and any new information you or your provider send, and in some cases it may ask for another 14 days.2 When the review is done, the plan must send you a written Notice of Appeal Resolution.

If you disagree with the Notice of Appeal Resolution, you can ask the Oregon Health Authority for a contested case hearing within 120 days of the date on that resolution.2 There is one way to reach the state hearing without waiting for that notice: if the plan fails to adhere to the federal notice and timing requirements for appeals, you are deemed to have exhausted the plan's appeal process and can request a state fair hearing directly.2

As of 2026, the coordinated care organizations serving Oregon Health Plan members are the following.2

• Advanced Health
• AllCare CCO
• Cascade Health Alliance
• Columbia Pacific Coordinated Care Organization
• Eastern Oregon Coordinated Care Organization
• Health Share of Oregon
• InterCommunity Health Network Coordinated Care Organization
• Jackson Care Connect
• PacificSource Community Solutions (Central Oregon, Columbia Gorge, and Marion/Polk regions)
• Trillium Community Health Plan (Southwest and Tri-County)
• Umpqua Health Alliance
• Yamhill Community Care

The plan rosters change with the coordinated care organization contract cycle, so confirm your plan's name on your member card or in your notice.

How to request a fair hearing in Oregon

Filing the right form with the right office is what avoids an avoidable delay. In Oregon, the Oregon Health Plan administrative hearing is requested from the Oregon Health Authority, and there are two ways to file.2

If your denial came directly from the Oregon Health Authority under fee-for-service, you ask the Oregon Health Authority for a hearing without a coordinated care organization appeal first, within 60 calendar days of the date on its Notice of Denial.2 Whichever path applies, request that your benefits continue at the same time you file, and do it within the 10-day continuation window described above.

Learn More

Find personalized help navigating an Oregon Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.