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 guarantees every Medicaid applicant and member the right to a fair hearing before the state agency when a claim for medical assistance is denied or not acted on promptly, and when the person believes the agency acted erroneously.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, that notice must be sent whenever a plan denies or limits a service, reduces or ends a service it had already approved, denies payment, or fails to act within the required time.4 In practice, you can appeal:

• A denial of an OHP application or of a specific covered service
• A prior authorization denial or a level-of-care determination
• 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 internal 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.5

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.3 Federal law also caps the general fair hearing request at 90 days from the date a notice is mailed.6

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.2

How to keep your benefits during the appeal

Under federal law, if the agency sent the required advance notice and you request the appeal or hearing in time, your services continue until a decision is reached.7 Oregon calls this continuing your benefits, and lawyers call it aid paid pending.

To keep a service you are already receiving, 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 from the plan or the state.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.

If waiting for a standard decision could seriously jeopardize your health, you can ask for expedited review, and the Oregon Health Authority decides urgent cases within 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 put your request to continue benefits in writing 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 exhaust the plan's internal appeal before the Oregon Health Authority will hold a hearing.2 Skipping that step and going straight to the state gets the hearing request dismissed.

The internal 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 take another 14 days to finish the review.2 When the review is done, the plan sends you a written Notice of Appeal Resolution.

Only after that resolution can you request the state hearing. If the Notice of Appeal Resolution upholds the denial, you can ask the Oregon Health Authority for a contested case hearing within 120 days of the date on that resolution.2 If the plan fails to meet its own notice and timing rules, the federal managed care regulations treat the appeal as exhausted so you can proceed to a state hearing.4

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 handled by the Oregon Health Authority's Medical Hearings unit, 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.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.