Member Rights

• Be cared for by people who respect your privacy and dignity.
• Be informed about Samaritan Health Plans, our providers, and the benefits and services you have available to you as a member.
• Receive information that helps you select a qualified practitioner whom you trust and with whom you feel comfortable.
• A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• Receive information and clinical guidelines from your health care provider or your health plan that will enable you to make thoughtful decisions about your health care.
• Actively participate in decisions that relate to your health and your medical care through discussions with your health care provider or through written advance directives.
• Have access to medical services that are appropriate for your needs.
• Express a concern or an appeal and receive a timely response from Samaritan Health Plans.
• Have your claims paid accurately and promptly.
• Request a review of any service not approved, and to receive prompt information regarding the outcome.
• Be informed about and make recommendations regarding Samaritan Health Plans’ member rights and responsibilities policy.
• Refuse care from specific providers. 

Read and understand the information in and the terms of your plan. SHP will have no liability whatsoever for your misunderstanding, misinterpretation or ignorance of the terms, provisions, and benefits of this plan. If you have any questions or are unclear about any provision concerning this Plan, please contact us. We will assist you in understanding and complying with the terms of the plan.

• Talk openly with your physician or provider, understand your health problem and work toward a relationship built on mutual trust and cooperation.
• Develop mutually agreed-upon treatment goals with your qualified practitioner, to the degree possible, and follow treatment plans and instructions.
• Supply, to the extent possible, information Samaritan Health Plans and your physicians or providers need to provide care.
• Do your part to prevent disease and injury. Try to make positive, healthful choices. If you do become ill or injured, seek appropriate medical care promptly.
• Treat your physicians or providers courteously.
• Make your required copayment at the time of service.
• Show your member identification card whenever you receive medical services.
• Let us know if you have concerns or if you feel that any of your rights are being compromised, so that we can act on your behalf.
• Call or write within 180 days of date-of-service if you wish to request a review of services provided or appeal a Samaritan Health Plans decision.
• Notify Customer Service if your address changes.

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. SHP will attempt to address your grievance generally within 30 days of receipt. You may receive information about the grievance and appeal processes by contacting Customer Service.

You also have the right to file a complaint and seek assistance from the Division of Financial Regulation.

By calling:  503-947-7984 or the toll free message line at 888-877-4894.

By e-mail:  DFR.InsuranceHelp@oregon.gov.

By writing:

Oregon Division of Financial Regulation Consumer Advocacy Unit
PO Box 14480
Salem, OR 97309-0405

By going online to Oregon Division of Financial Regulation Consumer Advocacy.

If you disagree with SHP’s decision regarding 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.
4. Received by us within 180 days of the denial or other action giving rise to the appeal.

You can use this Appeal Request form or contact Customer Service to request a copy. Please include as much information as possible including the date of the incident, the names of individuals involved, and the specific circumstances.

When filing a grievance or appeal:

• You can submit for consideration any written comments, documents, records and other materials relating to the Adverse Benefit Determination.
• 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 days of receiving the appeal, SHP will send you or your authorized representative an acknowledgment letter. You or your authorized representative have 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 SHP receiving your appeal request.

Please note: If you, your authorized representative or your treating provider believe the request to appeal is urgent (meaning, a review decision made within the standard timeframe of 30 days could seriously jeopardize your life, 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.
(ii) Provide SHP with a signed Record Request Form to release medical records to the IRO.

The waiver with instructions and a return address and fax number are 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 5 business days of the request for external review.

Members can obtain a copy of the waiver at samhealthplans.org/EmployerGroupForms or call Customer Service at the phone number listed on the back of  your membership card to request a copy of the waiver. If Samaritan Health Plans does not receive the signed waiver from the member within five business days of the request for external review, the external review request is deemed ineligible and we will be unable to proceed with the external review process at that time. However, if the member supplies the signed waiver after the end of the five business days but before the end of the 180-day eligibility period for external review, we will accept the submitted document and proceed with the external review process. For the purposes of any internal recordkeeping or communication with the member about the external review process that is not specifically required by law or rule, the plan may treat a late waiver submission as part of the original request for external review. However, for the purposes of the external review timeline, insurers must treat a late submission of a signed waiver as the initiation of a new external review request.

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

1. The plan does not adhere to the rules and guidelines of the process defined for the internal review.
2. The Level 1 appeal has been completed.
3. The reason for the Level 1 adverse decision was:

• Based on medical necessity.
• For the purpose of continuity of care (no interruption of an active course of treatment).
• 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 the Expedited Appeal Process section.

Once Samaritan Health Plans has been notified of the assigned IRO, SHP will submit your external review request to the IRO within five business days. When you are notified by the IRO that your request for external review has been received, you will have five business days to submit additional information about your appeal.

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

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

IRO decisions are final and SHP is bound by their decisions. SHP pays all costs for the handling of external review cases and administers these provisions in accordance with the law. If SHP does not comply with the IRO decision, SHP may be penalized by the Oregon Division of Financial Regulation, and you have the right to sue SHP 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 days of SHP 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.
• 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 days of SHP 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 have the right to sue.

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

Appeal Timelines

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

• Three 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 the SHP Customer Service Department for more information.

To submit your grievance or appeal, please contact the Customer Service Department at 541-768-4550 or toll-free at 800-832-4580 (TTY \800-735-2900\. Written grievances or appeals should be sent to: 

Samaritan Health Plans 
Appeals Team 
PO Box 1310 
Corvallis, OR 97339