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.
Members have the right to make a complaint about concerns or problems related to their coverage or care or to ask SHP to cover a specific medical service. These rights include:
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.
Oregon Division of Financial Regulation Consumer Advocacy UnitPO Box 14480Salem, 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:
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:
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 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 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 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:
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:
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.
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:
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.
Samaritan Health Plans has the following timeframes for making internal review decisions on 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
This Notice of Privacy Practices describes your privacy rights and our responsibilities to safeguard your health information.
Samaritan Health Plans does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or publication in its programs, services and activities or in employment. For more information or to report a compliant, please review our Nondiscrimination Notice.
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