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Understanding Your Member Rights

Samaritan Health Plans understands that you may have questions or concerns about your benefits, eligibility, the quality of care you receive or how we reached a claim determination or handled a claim. We try to answer your questions promptly and give you clear, accurate answers.

 

If you have a question, concern or complaint about your coverage, please contact Customer Service. Many times, Customer Service can answer your question or resolve an issue to your satisfaction right away. If you feel your issues have not been addressed, you have the right to submit a grievance and/or appeal in accordance with the information outlined below.

Customer Service 

You may receive information about our grievance and appeal processes from Customer Service at 541-768-4550 or toll free at 800-832-4580 (TTY 800-735-2900).

Filing a Grievance

If you are dissatisfied with the availability, delivery or the quality of health care services or claims payment, handling or reimbursement for health care services, you or your authorized representative can file your grievance in writing. We will send you or your authorized representative an acknowledgment letter once your grievance is received. If the grievance cannot be resolved, we will notify you in writing that additional time is required. We will try our best to provide you or your authorized representative with a written decision within 30 days of receiving your initial letter.

 

You may receive information about our grievance and appeal processes by contacting Customer Service.

Filing a Level 1 Appeal

If you disagree with our decision about your medical bills or health care services, you or your authorized representative may submit an appeal of an Adverse Benefit Determination. The appeal request must be:

  1. in writing;
  2. signed;
  3. include the appeal reason; and
  4. received by us within 180 days of the denial or other action giving rise to the appeal.    

You can use an Appeal Request Form available from Customer Service to provide this information. Please include as much information as possible including the date of the incident, the names of individuals involved and the specific circumstances.

 

In filing a grievance or appeal:

  • You can submit for consideration any written comments, documents, records and other materials relating to the Adverse Benefit Determination; and
  • You can, upon request and free of charge, have reasonable access to and copies of the documents, records and other information relevant to the Adverse Benefit Determination.     

Within seven (7) days of receiving the appeal, we will send you or your authorized representative an acknowledgment letter. You or your authorized representative has the right to appear in person to talk about your appeal. The level 1 appeal decision will be determined by a health care professional not previously involved in your initial Adverse Benefit Determination. You or your authorized representative will receive a written decision within 30 days of our receiving your appeal request.

 

Please note: If you, your authorized representative or your treating provider believes that the request to appeal is urgent (meaning, a review decision made within the standard timeframe of 30 days could seriously jeopardize your life or health or your ability to regain maximum function), your appeal will be processed in an expedited manner. For urgent appeals, your treating provider can act as your authorized representative.  

 

If your request for appeal meets the definition of urgent, you or your authorized representative can request a simultaneous expedited external review. For more information, please refer to expedited appeal process below.

External Review

External Review decisions are made by Independent Review Organizations (IRO) that are not associated with Samaritan Health Plans. When an appeal is upheld by the Plan, a letter notifying you of the decision is sent along with a waiver form within 30 days. If you are dissatisfied with the Plan’s adverse decision, you or your authorized representative may have the right to request an external review.

 

To be eligible for external review, the Member must (i) have exhausted the Internal Appeals process shown above; and (ii) provide us a signed Authorization to Use and Disclose Health Information (waiver) to release medical records to the IRO. The waiver with instructions and a return address and fax number is provided directly to the member with an adverse appeal determination. If a signed waiver was not included with the member’s external review request, several attempts to obtain the waiver will be made. Attempts will be made to reach the member by phone, mail and/or email within five (5) business days of the request for external review. Members can obtain a copy of the waiver on the Samaritan Health Plans website at samhealthplans.org or call Customer Service at the phone number listed on the back of your membership card to request a copy of the waiver. If we do not receive the signed waiver from the member within five (5) business days of the request for external review, the external review request is deemed ineligible and the process will terminate.

 

Additionally, your appeal can qualify for an external review (at no cost to you) if:

  • The Plan does not adhere to the rules and guidelines of the process defined for the internal review.
  • The Level 1 appeal has been completed and the reason for the Level 1 adverse decision was:
    • based on medical necessity;
    • for treatment determined to be experimental or investigational;
    • for the purpose of continuity of care (no interruption of an active course of treatment); or
  • You and the Plan have mutually agreed to waive the internal appeals requirement    

We must receive your written request for an external review within 180 days of the Level 1 adverse decision.

 

Please note: If your request meets the definition of urgent as defined by law, you or your authorized representative can request an expedited external review. For more information, please refer to expedited appeal process. Once Samaritan Health Plans has been notified of the assigned IRO, we will submit your external review request to the IRO within vie (5) business days. When you are notified by the IRO that your request for external review has been received, you will have five (5) business days to submit additional information about your appeal.

he IRO will return a written decision to you or your authorized representative and to the Plan within the following timeframes:

  • Expedited external review – three (3) days after receipt of the request.
  • Standard external review – 30 days after receipt of the request    

IRO decisions are final and we are bound by their decisions. We pay for all costs for the handling of external review cases and administer these provisions in accordance with the law. If we do not comply with the IRO decision, we may be penalized by the Oregon Division of Financial Regulation, and you have the right to sue us under applicable Oregon law.

Expedited Review Process

If you believe your appeal is urgent, You, your authorized representative or your treating provider, can request an expedited review. If the appeal request meets the definition of urgent under the law; which means, a decision made within the standard timeframe of 30 days could seriously jeopardize your life or health or your ability to regain maximum function, the appeal will be processed in an expedited manner (within three (3) days of our receiving the appeal request). If the Appeal does not meet the definition of urgent, you will be notified immediately, and the Appeal will then be processed within the standard timeframe.

 

The expedited review request must:

  • be filed verbally or in writing within 180 days after you receive notice of the initial written pre-service denial;
  • state the reason for the appeal request; state the reason an expedited decision is needed; and
  • include supporting documentation necessary to make a decision.

When applicable, if you are simultaneously requesting an expedited external review in addition to an expedited internal review, a signed waiver granting the IRO access to your medical records pertaining to the adverse decision must be included.

The internal expedited review decision will be determined by a health care professional not previously involved in your case. A verbal notice of the decision will be provided to you, your authorized representative and your treating provider as soon as possible, but no later than three (3) days of our receiving the appeal. A written notice will be mailed within one working day following the verbal notification.

 

If you have requested a simultaneous expedited external review, Samaritan Health Plans will also forward your appeal to the IRO. Once the IRO has made a decision, Samaritan Health Plans is obligated to follow and honor the decision that was made by the IRO, regardless of the decision or opinions made by Samaritan Health Plans. If Samaritan Health Plans does not honor the decision made by the IRO, you or your authorized representative has the right to sue.

 

To apply for an expedited review, you must send your written request or the Appeal Request Form to Samaritan Health Plans.

Appeal Timeframes

Samaritan Health Plans has the following timeframes for making internal review decisions on appeals:

  • Three (3) days for urgent Appeals 30 days for pre-service Appeals    
  • 30 days for post-service appeals

To obtain an Appeal Request Form or a waiver granting IRO access to your medical records, please contact our Customer Service Department for more information.