Appeals
Specific circumstances allow a provider to appeal for a medical, pharmacy, or durable medical equipment (DME) authorization or payment denial on behalf of a patient. Samaritan Health Plans follows strict rules and regulations set forth by Medicaid, Medicare, and the Federal Government. These rules and regulations are subject to change.
Appeal Request Forms
Appeal Request Form for Samaritan Advantage
Appeal Request Form for all Other Plans
Instructions
For further information regarding appeal rights, time frames and forms, choose the insurance plan in the drop down menu below that applies to your situation.
Non-contracted providers for Samaritan Advantage members should refer to requirements for non-contracted providers.
Medical Appeals
| Urgent: Pre-service Medical | Standard: Pre-service Medical | Payment Denial: Medical | |
|---|---|---|---|
| Instructions | Details | Details | Details |
| Contracted Treating Physician |
Please provide a verbal or written request directly to Samaritan Health Plans. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, Toll-free 1-888-435-2396 Email: |
The provider must notify the member. No forms are required. Only the treating physician can appeal on the patient’s behalf without filling out a CMS-1696 form. | Complete the CMS 1696 Form |
| Non-contracted Treating Physician | The provider must notify the member. No forms are required. Only the treating physician can appeal on the patient’s behalf without filling out a CMS-1696 form. | Member notification only — No forms required. | Complete the CMS 1696 Form |
| Other Providers (non-care specific, i.e., labs, anesthesia) | Does not apply. |
Please complete Authorization Representative form, CMS 1696 Form. Send email to: |
Contracted providers: Complete the CMS 1696 Form Non-contracted providers: Complete Waiver of Liability Form Send email to: SHPOAppealsTeam@ samhealth.org |
Reimbursement and Covered Service Denials
Please contact customer service with questions and concerns about reimbursement and covered service denials. Our customer service department is available to provide assistance Monday - Friday, 8 a.m. to 6 p.m. PT.
Urgent: Pre-service Medical Appeals
This applies when the patient has not received the service and the physician believes that applying the standard appeal time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function. Any treating physician can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans without filling out CMS-1696 form.
Standard: Pre-Service Medical Appeals
This applies when the patient has not received the service. Medicare assumes the treating physician has documented a conversation with the patient regarding the intent to appeal on their behalf. Only the treating physician can appeal on the patient’s behalf without filling out a CMS-1696 form.
Payment Denial: Medical
Any treating provider can appeal on their patient’s behalf after completing an Appointment of Representative form, such as the CMS 1696 form, a legal court appointed representative document, or the equivalent before the appeal can be processed. Please fill out, print and sign the Medicare Appointment of Representative form, CMS 1696 Form, and include this with your appeal.
Any non-contracted provider can appeal a denied payment but only after completing a waiver of liability.
Samaritan Advantage Appeal Form
Send the forms, the appeal request and any supporting documentation to SHPO:
Mail: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330
Fax: 541-768-9765
Email: SHPOAppealsTeam@samhealth.org
Pharmacy Appeals
| Urgent: Pre-service Pharmacy | Standard: Pre-service Pharmacy | Payment Denial: Pharmacy | |
|---|---|---|---|
| Instructions | |||
| Contracted Treating Physicians |
Any provider or prescriber can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans without filling out a CMS-1696 form. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330 Fax: 541-768-9765 Phone: Corvallis: 541-768-5207, Toll-free: 1-888-435-2396 Email: |
Any provider or prescriber can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans without filling out a CMS-1696 form. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330 Fax: 541-768-9765 Phone: Corvallis: 541-768-5207, Toll-free: 1-888-435-2396 Email: |
Any provider or prescriber can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans without filling out a CMS-1696 form. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330 Fax: 541-768-9765 Phone: Corvallis: 541-768-5207, Toll-free: 1-888-435-2396 Email: |
| Non-contracted Treating Physicians | See above. | See above. | See above. |
| Other Providers (non-care specific, i.e., labs, anesthesia) | See above. | See above. | See above. |
Reimbursement and Covered Service Denials
| Complete the CMS 1696 Form |
| Complete the CMS 1696 Form Reimbursement and Covered Service Denials |
Please contact customer service with questions and concerns about reimbursement and covered service denials. Our customer service department is available to provide assistance Monday - Friday, 8 a.m. to 6 p.m. PT.
Urgent: Pre-service Pharmacy Appeals
This applies when the patient has not received the medication and the provider/prescriber believes that applying the standard appeal time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function. Any provider/prescriber can appeal a pre-service denial on their patient’s behalf by submitting an oral or written request directly to Samaritan Health Plans without filling out a CMS-1696 form.
Standard: Pre-Service Pharmacy Appeals
This applies when the patient has not received the medication. Medicare assumes the provider/prescriber has documented a conversation with the patient regarding the intent to appeal on their behalf. Any provider/prescriber can appeal on the patient’s behalf without filling out a CMS-1696 form.
Payment Denial: Pharmacy
Any provider/prescriber can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans without filling out a CMS-1696 form. This applies when the patient has not received the medication and the provider/prescriber believes that applying the standard appeal time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function.
Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330
Fax: 541-768-9765
Phone:Corvallis: 541-768-5207, Toll-free: 1-888-435-2396
Email: SHPOAppealsTeam@samhealth.org
Time Frames to Appeal and Processing Times
| Urgent: Pre-service Medical | Standard: Pre-service Medical and Pharmacy | Payment Denial: Medical | Payment Denial: Pharmacy | |
|---|---|---|---|---|
| Time Frame to Appeal | Within 60 calendar days from the date on the denial notice | Within 60 calendar days from the date on the denial notice | Within 60 calendar days from the date on the denial notice | Within 60 days from the initial decision |
| Appeal Processing Time | 72 hours |
Medical= 30 calendar days Pharmacy = 7 calendar days |
Expedited = 72 hours Standard pre-service = 30 calendar days Standard post-service = 60 calendar days |
Expedited = 72 hours Standard = 7 calendar days |
Medical Appeals
| Urgent: Pre-service Medical | Standard: Pre-service Medical | Payment Denial: Medical | Payment Denial: Pharmacy | |
|---|---|---|---|---|
| Instructions | Details | Details |
Details | Details |
| Contracted Treating Physician |
Provide verbal or written documentation of medical necessity to Samaritan Health Plans (SHP). Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, Toll-free 1-888-435-2396 Email: SHPOAppealsTeam@ samhealth.org |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Email: SHPOAppealsTeam@ samhealth.org |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Email: SHPOAppealsTeam@ samhealth.org |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Email: SHPOAppealsTeam @samhealth.org |
| Non-contracted Treating Physician | See above. | See above. | See above. | See above. |
| Other Provider (non-care specific, i.e., labs, anesthesia) | See above. | See above. | See above. | See above. |
Time Frames to Appeal and Processing Time
| Urgent: Pre-Service Medical | Standard Pre-service: Medical | Payment Denial: Medical | Payment Denial: Pharmacy | |
|---|---|---|---|---|
| Time Frame to Appeal | Within 180 days from the date on the denial notice | Within 180 days from the date on the denial notice | Within 180 calendar days from the date on the denial notice | Within 180 days from the initial decision |
| Appeal Processing Time | 72 hours | 30 calendar days | Payment: 60 calendar days |
Standard = 30 calendar days |
Reimbursement and Covered Service Denials
Please contact customer service with questions and concerns about reimbursement and covered service denials. Our customer service department is available to provide assistance Monday - Friday, 8 a.m. to 6 p.m. PT.
Urgent Situations
This applies when the patient has not received the service and the physician believes that applying the standard appeal time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function, or the patient’s pain cannot be controlled by means other than by the service that was denied. Any provider can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to SHP with a supporting statement as to why an expedited or urgent request is necessary.
Standard Pre-Service and Payment Denials (Medical and Pharmacy)
A provider can appeal on the patient’s behalf only with written permission from the patient or their authorized representative. A copy of the written permission, signed and dated by the patient or authorized representative, must be received by Samaritan Health Plans before the provider’s appeal will be processed.
Please submit your appeal letter with member’s (or member’s authorized representative) written consent to:
Mail: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330
Fax: 541-768-9765
Medical Appeals
| Urgent: Pre-service Medical | Standard Pre-Service: Medical | Payment Denial: Medical | Payment Denial: Pharmacy | |
|---|---|---|---|---|
| Instructions | Details | Details | Details | Details |
| Contracted Treating Physician |
Provide verbal or written documentation of medical necessity to SHP. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
Provide written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
| Non-Contracted Treating Physician | See above. | See above. | See above. | See above. |
| Other Provider (non-care specific, i.e., labs, anesthesia) |
Not available. | See above. |
See above. |
See above. |
Time Frames to Appeal and Processing Time
| Urgent: Pre-Service Medical | Standard Pre-service: Medical | Payment Denial: Medical Appeals | Payment Denial: Pharmacy Appeals | |
|---|---|---|---|---|
| Time Frame to Request Appeal | Within 60 calendar days from the date on the denial notice | Within 60 days from the date on the denial notice | Within 60 calendar days from the date on the denial notice | Within 60 days from the initial decision |
| Appeal Processing Time | 3 business days | 16 calendar days |
Expedited = 3 business days Standard pre-service = 16 calendar days Standard post-service = 16 calendar days
|
Expedited = 3 business days Standard pre-service = 16 calendar days Standard post-service = 16 calendar days |
Reimbursement and Covered Service Denials
Please contact customer service with questions and concerns about reimbursement and covered service denials. Our customer service department is available to provide assistance Monday - Friday, 8 a.m. to 6 p.m. PT.
Urgent Situations
This applies when the patient has not received the service and the physician believes that applying the standard appeal time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function, or the patient’s pain cannot be controlled by means other than by the service that was denied. Any provider can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to IHN-CCO with a supporting statement as to why an expedited or urgent request is necessary.
Standard Pre-Service and Payment Denials (Medical and Pharmacy)
A provider can appeal on the patient’s behalf only with written permission from the patient or authorized representative. A copy of the written permission, signed and dated by the patient or authorized representative, must be received by IHN-CCO along with the appeal request before the provider’s appeal will be processed.
Please submit your appeal letter with the member’s (or member’s authorized representative) written consent to:
Mail: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330
Fax: 541-768-9765
Email: SHPOAppealsTeam@samhealth.org
The first step in the appeal process for commercial plan members is for the patient to file a grievance with the health plan. Once the grievance is resolved the provider can request an appeal on behalf of the patient.
Instructions
| Expedited Pre-service Appeals | Medical Necessity & Experimental Appeals | Medical Necessity & Experimental Claims | Standard Pre-service Appeals | Payment Denial | |
|---|---|---|---|---|---|
| Instructions | — | — | Details | — | |
| Member’s Contracted Treating Physician | Provide verbal or written documentation of medical necessity to SHP.
Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
Provider has the right to appeal if the service is denied as not medically necessary or experimental.
Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
Provider has the right to appeal if the service is denied as not medically necessary or experimental. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 |
All other denials require written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Email: SHPOAppeals Team@samhealth.org |
All other denials require written consent from member or member’s authorized representative. Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330 Fax: 541-768-9765 Email: SHPOAppeals Team@samhealth.org |
| Member’s Non-contracted Treating Physician | See above. | See above. | See above. | See above. | See above. |
| Other Provider (non-care specific, i.e., labs, anesthesia) | Not available. | See above. | See above. | See above. | See above. |
Time Frames to Appeal and Processing Time
| Expedited Pre-Service | Medical Necessity / Experimental Only | Medical Necessity / Experimental Only | Pre-Service Appeal | Payment Denial: Medical | Payment Denial: Pharmacy | |
|---|---|---|---|---|---|---|
| Time Frame to Appeal | Within 180 days from the date on the denial notice | Within 180 days from the date on the denial notice | Within 180 days from the date on the denial notice | Within 180 days from the date on the denial notice | Within 180 calendar days from the date on the denial notice | Within 180 days from the initial decision |
| Appeal Processing Time | 72 hours | 15 calendar days | Payment: 30 calendar days | 15 calendar days |
Expedited = 72 hours Standard pre-service = 15 calendar days Standard post-service = 30 calendar days |
Standard = 15 calendar days |
Expedited Pre-service Appeals
This applies when the patient has not received the service and the physician/practitioner believes that applying the standard appeal processing time frame could seriously jeopardize the patient’s life, health, mental health or ability to regain maximum function, or the patient’s pain cannot be controlled by means other than by the service denied. Any provider can appeal a pre-service denial on their patient’s behalf by submitting a verbal or written request directly to Samaritan Health Plans with a supporting statement as to why an expedited or urgent request is necessary.
Mail to: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis OR 97330
Fax: 541-768-9765
Phone: Corvallis 541-768-5207, Toll-free 1-888-435-2396
Email: SHPOAppeals Team@samhealth.org
Standard Pre-Service and Payment Denials
A provider can appeal on the patient’s behalf with written permission from the member or member’s authorized representative. A copy of the written permission, signed and dated by the member or authorized representative must be received by Samaritan Health Plans before the provider’s appeal will be processed.
Please submit appeal letter with member’s (or member’s authorized representative) written consent to:
Mail: Attention Appeals Team, Samaritan Health Plans, PO Box 1310, Corvallis, OR 97330
Fax: 541-768-9765
Medication Exceptions & Redeterminations
If your patient’s medication is not listed, you can ask us to make a medication exception to our coverage rules if they are a member of one of our plans that offer prescription drug coverage.
If your patient was denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.