Members of Samaritan Advantage Health Plans HMO have the right to make a complaint for concerns or problems related to their coverage or care or to ask us to cover a specific medical service. These rights include:
You can ask us to make a medication coverage determination or exception to our coverage rules if you are a member of one of our plans that offer prescription drug coverage: the Samaritan Advantage Premier Plan HMO; Samaritan Premier Plan Plus HMO; or the Samaritan Advantage Special Needs Plan HMO. This includes exceptions for:
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception request. If we approve your medication exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your medication exception request, you can appeal our decision.
A coverage determination may be requested by you, your appointed representative, your provider, or other prescriber in the following ways:Call Customer Service at 541-768-4550 or toll free 800-832-4580 (TTY 800-735-2900). Customer Service is available:
– OR -Complete a Medication Exception Form or a Coverage Determination Request Form (authorized representatives must also complete an Appointment of Representative Form) and submit to us:
Mail:Samaritan Advantage Health Plans HMOP.O Box 1310Corvallis, OR 97339
Fax:541-768-9776
Deliver:Samaritan Health Plans2300 NW Walnut Blvd., CorvallisMonday through Friday, 8:30 a.m. to 5 p.m.
A “grievance” is the type of complaint you make if you have any type of problem with Samaritan Advantage Health Plans HMO or one of our plan providers. You would file a grievance if you have a problem with, for example, the quality of your care, waiting times for appointments or time spent in the waiting room, the way your doctors, pharmacists or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office or pharmacy. A grievance needs to be filed within 60 days of the event.
If you have a grievance, we encourage you to first call Customer Service at 541-768-4550 or toll free 800-832-4580 (TTY 800-735-2900).Customer Service is available:
You may also:
We will try to resolve any grievance that you might have over the phone. In addition, we will send you a written response to your phone grievance. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
You can also find more information on how to file a grievance or an expedited grievance with our plan in your Evidence of Coverage. If you are a Conventional plan member, you will find step-by-step instructions on how to file a grievance in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.
In addition to the grievance (complaint) you have sent to us, you also have the right to report the quality of care issue to the independent review agency KEPRO who is contracted with Medicare as the Quality Improvement Organization (QIO). You may contact KEPRO by writing or calling the information below:
KEPRO5700 Lombardo Center Dr., Suite 100Seven Hills, OH 44131Toll free: 888-305-6759TTY: 855-843-4776Fax: 833-868-4064
An appeal is a formal way of asking us to review and change a coverage decision we have made. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Samaritan Advantage Health Plans HMO or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Samaritan Advantage or one of our plan providers reduce or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal. If you think that we should have covered a prescription that was denied through the medication exception process, you can file an appeal.
For more information about your appeal rights, call us or see your Evidence of Coverage. If you are a Conventional plan member, you will find step-by-step instructions on how to file an appeal in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.
There are two kinds of appeals you can request:
You must file your request for appeal to Samaritan Advantage no later than 60 days after receiving the denial for your services or denial of payment. Samaritan Advantage will review your appeal request and make a determination as expeditiously as your health requires, but no later than 30 days from the date the appeal request was received. For payment it is 60 days from the date the appeal request is received.
You must file a request for appeal to Samaritan Advantage no later than 60 days from the date of the denial. Samaritan Advantage will review your appeal request and make a determination as expeditiously as your health requires, but no later than seven days from the date of the request.
You should include your name, address, member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), you prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
An appeal request form can be used to request an appeal of a medical care or prescription coverage decision made by our plan. You or your appointed representative can mail, email, or fax your written Appeal Request Form to Samaritan Advantage:
After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you some or all of the care or payment you want. If we turn down part or all of your request for medical service, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of Samaritan Health Plans. This organization will review your request and make a decision about whether we must give you the care or payment you want. If we turn down part or all of your request for a prescription, you may request an independent review organization to review your appeal.
If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go onto additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. For more information please contact Customer Service at 541-768-4550 or toll free 800-832-4580 (TTY 800-735-2900). Customer Service is available:
Members are able to submit feedback about their Medicare health plan or Prescription Drug Plan directly to Medicare. Medicare values the satisfaction of its members and will use this information to continue to improve the quality of its program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (800-633-4227). TTY/TTD users can call 877-486-2048. Members can access the Medicare Complaint Form.
For help with complaints, grievances, and information requests, contact The Office of the Medicare Ombudsman.
To obtain an aggregate number of appeals, grievances and exceptions for Samaritan Advantage Health Plans HMO, please call our Customer Service Department. Or, if you, your authorized representative, or your provider have a question regarding the status of your appeal, grievance, medication exception or coverage determination, please contact our Customer Service Department at 541-768-4550 or toll free 800-832-4580 (TTY 800-735-2900). Customer Service is available:
An Organization Determination is a coverage decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You can also find more information on how to ask for a coverage decision in your Evidence of Coverage. If you are a Conventional plan member, you will find instructions on how to ask for a coverage decision in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.
An organization determination may be requested by you, your appointed representative, or your provider in the following ways:
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.
Page Updated 10-10-2024
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