Member Rights

• You have a right to receive information about Samaritan Choice Plans, our services, our providers and your rights and responsibilities.
• You have a right to be treated with respect and recognition of your dignity and right to privacy.
• You have a right to participate with your health care provider in decision-making regarding your health care.
• You have a right to honest discussion of appropriate or medically necessary treatment options.
• You are entitled to discuss those options regardless of how much the treatment costs or if it is covered by this plan.
• You have a right to the confidential protection of your medical information and records.
• You have a right to voice complaints about Samaritan Choice or the care you receive and to appeal decisions you believe are wrong.
• You have a right to make recommendations regarding the organization’s member rights and responsibilities policy.

• You are responsible for providing SCP and our providers with the information we need to care for you.
• You are responsible for following treatment plans or instructions agreed on by you and your health care providers.
• You are responsible for payment of copays at the time of service.
• You are responsible for reading and understanding all materials about your health plan benefits and for making sure that family members covered under this plan also understand them.
• You are responsible for making sure services are prior authorized when required by this plan before receiving medical care.
• You are responsible for understanding your health problems and participating in developing mutually agreed upon treatment goals to the degree possible.

Grievance means a written complaint regarding:

• Availability, delivery or quality of health care services.
• Claims payment, handling or reimbursement for health care services.

You or your authorized representative may file a grievance:

• In writing:  Samaritan Choice Plans Grievance Team
  PO Box 1310
  Corvallis, OR 97339
• By Fax:  541-768-9765
• By Email:  [email protected] 

You have the option to file a grievance (complaint) through SCP’s Grievance Team or you may choose to move straight to the appeal process without submitting a grievance.

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.

If you remain dissatisfied with the outcome of your grievance, you or your authorized representative may file a written appeal within 180 days of the denial or other action giving rise to the grievance.

Filing an Internal Appeal 

If you remain dissatisfied after the initial adverse benefit decision or grievance decision, you or your authorized representative have the right to file an appeal. The appeal request must be:

1. In writing.
2. Signed.
3. Include the appeal reason.
4. Received by SHP within 180 days of the denial or other action giving rise to the grievance. You may submit your appeal in writing with a brief explanation as to why you would like to appeal. You or your authorized representative have the right to appear in person to talk about your appeal.

Within seven business days of receiving the appeal, we 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.

During the internal review, SHP may require an extension for processing your pre-service appeal. If so, a letter will be sent to you explaining the circumstances requiring the extension and a description of any additional information needed from you or your providers. In no event will this extension exceed the time frames explained in the “Appeal timelines” section. If you do not agree with our decision to extend the timeframe to process your appeal, you may file a grievance.

You or your authorized representative will receive a written decision within 30 days (pre-service, plus extension if needed) or 60 days (post-service) of SHP receiving your appeal request.

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 or health or your ability to regain maximum function, your appeal will be processed in an expedited manner (three days after receipt of the request). Only pre-service requests qualify for expedited processing.

Urgent is determined when the member’s life or health would be in serious jeopardy or the member’s ability to regain maximum function would be impaired or the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.

You, your authorized representative or your treating provider may request a simultaneous expedited external review.

For more information, please refer to the “Expedited appeals” section.

External Review

If you are still dissatisfied with SHP’s final adverse determination, your appeal may qualify for an external review (at no cost to you) if any of the following apply:

• The plan does not adhere to the rules and guidelines of the process defined for the internal review.
• The internal review has been completed; and, the reason for the adverse decision was for any of the following:
  • Based on medical necessity.
  • For treatment determined to be experimental or investigational.
  • For the purpose of continuity of care.
• You and the plan have mutually agreed to waive the internal appeal requirement.

Your request for an external review must be received in writing to us within 120 days of our final adverse determination. Within five business days of receiving your request for external review, SHP will send you or your authorized representative a confirmation letter that your request is eligible for external review. (If your request is not eligible for external review, the plan will notify you or your authorized representative in writing and include the reasons for the ineligibility.)

To apply for an external review, you must send your written request or the Appeal Request form to SHP at the following address:

In writing: Samaritan Choice Plans Appeals Team

PO Box 1310
Corvallis, OR 97339

Fax: 541-768-9765

Email: [email protected]

External review decisions are made by randomly assigned Independent Review Organizations (IRO) who are not associated with Samaritan Health Services.

Please note: When you request an external review, the plan will send you or your authorized representative a waiver that allows the IRO access to your medical records pertaining to the internal appeal adverse decision. It is important for you to know that the plan can only continue to process your request if the signed waiver is returned.

The plan, upon receiving notification of the assigned IRO, will forward your request within five business days. You will receive a letter from the IRO informing you that your request for external review has been received. You will have 10 business days to submit additional information directly to the IRO.

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: 45 days after receipt of the request.

IRO decisions are final and SHP is bound by their decisions. If you want more information regarding external review, please refer to the “Member resources” section to contact Customer Service.

Expedited appeals

Urgent is determined when the member’s life or health would be in serious jeopardy or the member’s ability to regain maximum function would be impaired or the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.

If you believe your appeal is urgent, you, your authorized representative or your treating provider may request an expedited appeal. If the appeal request meets the definition of urgent; meaning, 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 after receipt of the request).

For urgent appeals, your treating provider may act as your authorized representative without a signed Authorized Representative form.

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.
When applicable, you may simultaneously request an expedited external review, in addition to an expedited internal review.
An expedited external review may be filed verbally or in writing within 120 days of our initial or final adverse determination.
An expedited internal review may be filed verbally or in writing within 180 days after you receive notice of the initial adverse determination.

The expedited appeal request must:

• Be based on a pre-service adverse determination.
• State the reason for the appeal request.
• State the reason an expedited decision is needed.
• Include supporting documentation necessary for the plan to make a decision.

The internal expedited review decision will be determined by an appropriate 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 after receipt of the request. A written notice will be mailed within one working day following the verbal notification.

For an expedited external review, the randomly assigned IRO will have three days to make their decision from the time they receive the appeal information from the plan.

To apply for an internal or external expedited review, send your written request along with a completed Authorization to Release Health Plan Records for External Review form to:

In writing: Samaritan Choice Plans Appeals Team

PO Box 1310
Corvallis, OR 97339

Fax: 541-768-9765

Email: [email protected]

Call Customer Service at 541-768-4550 or toll free at 800-832-4580 (TTY 800-735-2900).

Appeal timelines

Samaritan Choice Plans adheres to the following timeframes for making decisions for an internal appeal:

• Three days for urgent.
• 30 days for pre-service.
• 60 days for post-service.

SCP may take an extension of up to 14 days for pre-service appeals. You will be notified in writing if an extension is necessary.

Forms:

You may obtain the following forms for your appeal by contacting Customer Service at 541-768-4550 or toll free at 800-832-4580 (TTY 800-735-2900) or online at samhealthplans.org/ChoiceForms:

• Authorized Representative.
• Appeal Request.

You have the right to:

• File a grievance about and appeal any decision we make regarding availability, delivery or quality of health care services, including claims payment, handling or reimbursement for health care services or matters pertaining to the contractual relationship between the member and the plan.
• Contact SHP when you:
  – Do not understand the reason for the denial.
  – Do not understand why the health care service or treatment was not fully covered.
  – Do not understand why a request for coverage of a health care service or treatment was not approved.
  – Cannot find the applicable provision in your plan document.
  – Want a copy (free of charge) of the guideline, criteria or clinical rationale that we used to make our decision. 
• A full and fair internal review of your appeal by individuals associated with SHP, but who were not involved in the adverse decision. 
• Provide SHP with additional information that relates to your appeal.
• Appear in person to talk about your internal appeal.
• An internal review decision within 30 days for pre-service appeals, 60 days for post-service appeals and three days for an expedited appeal.
• File an external review (at no cost to you) if applicable.
• An external review decision within 45 days of the IRO receiving your standard request and three days for an expedited request.
• Send additional information, in writing, directly to the IRO.
• An expedited review if you, your authorized representative or your treating provider believes that waiting the standard 30-day timeframe would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed. (Urgent is determined when the member’s life or health would be in serious jeopardy or the member’s ability to regain maximum function would be impaired or the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.)
•  A simultaneous expedited internal and external review, if applicable.
• Want a copy (free of charge) of the guideline, criteria or clinical rationale that SHP used to make our decision.

For information about the grievance and appeal processes, contact Customer Service:

By phone: 541-768-4550 or toll free at 800-832-4580 (TTY 800-735-2900).
In writing: Samaritan Choice Plans Appeals Team
PO Box 1310
Corvallis, OR 97339
Fax: 541-768-9765
Email: [email protected]

You also have the right to file a complaint and seek further assistance if you are unsatisfied with how your appeal or grievance was handled by Samaritan Health Plans or if you remain unsatisfied with the outcome of your appeal or grievance:

By phone: 206-757-6781
In writing: U.S. Department of Labor, Seattle District Office
300 Fifth Avenue, Ste. 1110
Seattle, WA 98104
Fax: 206-757-6662