Members have the right to make a complaint regarding concerns or problems related to their coverage or care or to ask us to cover a specific medical service. These rights include:
Grievance means a written complaint regarding:
You or your authorized representative may file a grievance:
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.
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:
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.
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:
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 1310Corvallis, OR 97339
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:
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.
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:
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:
Call Customer Service at 541-768-4550 or toll free at 800-832-4580 (TTY 800-735-2900).
Samaritan Choice Plans adheres to the following timeframes for making decisions for an internal appeal:
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.
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:
You have the right to:
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 TeamPO Box 1310Corvallis, OR 97339Fax: 541-768-9765Email: SHPOappealsteam@samhealth.org
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: 206-757-6781In writing: U.S. Department of Labor, Seattle District Office300 Fifth Avenue, Ste. 1110Seattle, WA 98104Fax: 206-757-6662
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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