Appeals

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 888-435-2396 Email:  SHPOAppealsTeam@samhealth.org	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:  SHPOAppealsTeam@samhealth.org	Contracted providers: Complete the CMS 1696 Form Non-contracted providers: Complete Waiver of Liability Form Send email to: SHPOAppealsTeam@ samhealth.org

Reimbursement & 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 to 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.

CMS 1696 Form

Waiver of Liability Form

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	Details	Details	Details
Contracted Treating Physicians	Urgent: Pre-service Pharmacy 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: 888-435-2396 Email:  SHPOAppealsTeam@ samhealth.org	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: 888-435-2396 Email:  SHPOAppealsTeam@samhealth.org	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: 888-435-2396 Email:  SHPOAppealsTeam@samhealth.org
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 & 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 to 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: 888-435-2396

Email: SHPOAppealsTeam@samhealth.org

Time Frames to Appeal & Processing Times

	Urgent: Pre-service Medical	Standard: Pre-service Medical and Pharmacy	Payment Denial: Medical	Payment Denial: Pharmacy
Time Frame to Appeal	Urgent: Pre-service Medical 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 Medica	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 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 & 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 to 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.

Appeal Request Form

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

Email: SHPOAppealsTeam@samhealth.org

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 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, toll free 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)	Not available.	See above.	See above.	See above.

Time Frames to Appeal & 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 & 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 to 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 & Payment Denials (Medical & 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. 

Appeal Request Form

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	Details	Details	Details	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 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, toll free 888-435-2396 Email: SHPOAppeals Team@samhealth.org	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 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, toll free 888-435-2396 Email: SHPOAppeals Team@samhealth.org	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 Fax: 541-768-9765 Phone: Corvallis 541-768-5207, toll free 888-435-2396 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	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 & 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 888-435-2396

Email: SHPOAppeals Team@samhealth.org

Standard Pre-Service & 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.

Appeal Request Form

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

Email: SHPOAppealsTeam@samhealth.org