How to Appeal an EOCCO Denial
If EOCCO denied your medication, treatment, or equipment, you have the right to appeal. This guide walks you through every step, from filing an internal appeal to taking your case before an Administrative Law Judge.
Critical Deadlines
// Step-by-Step Appeal Process
Get Your Notice of Adverse Benefit Determination
When EOCCO denies, reduces, or terminates a service, they must send you a written notice. This notice must explain what was denied, why it was denied (citing specific OARs or policies), and your right to appeal.
What to look for:
- • The specific OAR or policy cited for the denial
- • The date on the notice (your 60-day clock starts here)
- • Instructions for filing an appeal
- • Whether you can continue receiving the service during appeal
OAR 410-141-3885 — Notice of Action/Adverse Benefit Determination
File an Internal Appeal with EOCCO
You have 60 days from the date on the notice to file an appeal. Appeals can be filed orally or in writing. If your situation is urgent, request an expedited appeal (resolved within 72 hours).
How to file:
- • Call EOCCO Member Services: 888-788-9821
- • Submit in writing to the address on your denial notice
- • Have your provider write a letter of medical necessity
- • Keep copies of everything you submit
OAR 410-141-3890 — Grievances & Appeals: Appeal Process
Request Continuation of Benefits
If EOCCO is reducing or terminating a service you are currently receiving, you can request that benefits continue during the appeal. You must request this before the effective date of the action.
Warning:
If you lose the appeal, EOCCO may require you to pay back the cost of continued services. However, this is often worth the risk when your health depends on the treatment.
OAR 410-141-3910 — Grievances & Appeals: Continuation of Benefits
If Denied Again: Request a Contested Case Hearing
If EOCCO upholds their denial, you can take your case before an Administrative Law Judge (ALJ) at the Office of Administrative Hearings. You have 120 days from the appeal resolution to request a hearing. The ALJ is independent and reviews the case fresh.
To request a hearing:
- • Call the Oregon Health Authority: 503-947-5120
- • Use form OHP 3302 (referenced in your denial notice)
- • You can also request an expedited hearing if urgent
- • You do NOT need a lawyer, but you can bring one
OAR 410-141-3900 — Grievances & Appeals: Contested Case Hearings
OAR 410-120-1860 — Contested Case Hearing Procedures
Prepare Your Case
The ALJ will review the evidence. The strongest cases include:
- A letter from your doctor explaining medical necessity
- The specific OAR that EOCCO cited, and evidence that they misapplied it
- EOCCO's own formulary showing the medication is covered
- Documentation of how the denial has harmed your health
- Records showing EOCCO failed to follow their own procedures
Use the OAR search tool below to look up the exact rules EOCCO is required to follow.
// Search Oregon Administrative Rules
Search all OAR Chapter 410 rules governing OHP, EOCCO, and Oregon Medicaid programs. Find the exact rule EOCCO cited in your denial, or look up your rights.
Database current as of February 21, 2026 — always verify with official sources
// Key Rules for Appeals
Grievances & Appeals: Definitions
Defines key terms used in the appeal process.
OAR 410-141-3885Notice of Adverse Benefit Determination
What EOCCO must include in denial notices.
OAR 410-141-3890Appeal Process
How to file an appeal, deadlines, resolution requirements.
OAR 410-141-3895Expedited Appeal
When you can request a faster appeal (72 hours).
OAR 410-141-3900Contested Case Hearings
Taking your case before an Administrative Law Judge.
OAR 410-141-3910Continuation of Benefits
Your right to keep receiving services during appeal.
OAR 410-120-1200Excluded Services & Limitations
What services Medicaid programs will not cover.
OAR 410-120-1855Client Rights & Responsibilities
Your fundamental rights as an OHP member.
// EOCCO Formulary & Coverage
The EOCCO formulary lists every medication covered under the plan, including tier levels and any restrictions (prior authorization, step therapy, quantity limits). If EOCCO denied your medication, check the formulary first — if the drug is listed, EOCCO may be violating their own coverage rules.
EOCCO Formulary 2025 (PDF)
Searchable PDF of all covered medications
Coverage Criteria Policies
Prior authorization and coverage requirements
Formulary Quick Reference
| Code | Meaning |
|---|---|
| Tier 1 | Generic Retail (lowest cost) |
| Tier 2 | Brand Retail |
| Tier 3 | Generic Specialty |
| Tier 4 | Brand Specialty |
| PA | Prior Authorization required (provider must get approval before dispensing) |
| ST | Step Therapy (must try “first line” medications first) |
| QL | Quantity Limit (limits on how much you can get per fill) |
| NC | Not Covered |
| EXC | Plan Exclusion |
| AMSP/LMSP | Ardon/Lumicera Mandatory Specialty Pharmacy (must use designated specialty pharmacy) |
// Tips from Experience
Verify the OAR they cited. EOCCO sometimes cites OAR sections that do not exist or do not say what they claim. Use the search tool above to read the actual rule text. If the rule does not support their denial, that is powerful evidence for your appeal.
Check their own formulary. If EOCCO denied a medication that appears on their own formulary as covered, point this out in your appeal. The formulary is a binding document.
Get everything in writing. If you file an appeal by phone, follow up with a written confirmation. Ask for written responses to every request. Agencies lose files — your copies are your protection.
You do not need a lawyer for a contested case hearing. The hearings are designed to be accessible. The ALJ will explain the process. Bring your medical records, your denial letters, and any supporting documentation.
Document the harm. Track what happened to your health during the denial period. If your condition worsened because of delayed treatment, that is relevant to the hearing and to any future complaints.
See how these rules were used — and broken
Our investigation documents how EOCCO denied critical diabetes care for 14 months, altered records, and cited nonexistent OAR sections.
Read: Denied, Delayed, Then Dismissed →Need help with an appeal? Have evidence of EOCCO misconduct?
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