Appeals

Specific circumstances allow a provider to appeal for a medical, pharmacy, or durable medical equipment (DME) authorization or payment denial on behalf of a patient. Samaritan Health Plans follows strict rules and regulations set forth by Medicaid, Medicare, and the Federal Government. These rules and regulations are subject to change. 

Appeal Request Forms

Appeal Request Form for Samaritan Advantage.

Appeal Request Form for All Other Samaritan Plans.

Instructions

For further information regarding appeal rights, time frames and forms, choose the insurance plan in the drop down menu below that applies to your situation. 

Non-contracted providers for Samaritan Advantage members should refer to requirements for non-contracted providers.

Medical Appeals

Urgent: Pre-service MedicalStandard: Pre-service MedicalPayment Denial: Medical
InstructionsDetailsDetailsDetails
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: 
[email protected]
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 PhysicianThe 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: 
[email protected]
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: [email protected]

Pharmacy Appeals

Urgent: Pre-service PharmacyStandard: Pre-service PharmacyPayment Denial: Pharmacy
InstructionsDetailsDetailsDetails
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: 
[email protected]
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: 
[email protected]
Non-contracted Treating PhysiciansSee 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: [email protected]

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 noticeWithin 60 calendar days from the date on the denial noticeWithin 60 days from the initial decision
Appeal Processing Time72 hoursMedical= 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 MedicaStandard: Pre-service MedicalPayment Denial: Medical Payment Denial: Pharmacy
InstructionsDetailsDetailsDetailsDetails
Contracted Treating PhysicianProvide 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 PhysicianSee 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 AppealWithin 180 days from the date on the denial noticeWithin 180 days from the date on the denial noticeWithin 180 calendar days from the date on the denial noticeWithin 180 days from the initial decision
Appeal Processing Time
72 hours30 calendar daysPayment: 60 calendar daysStandard = 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: [email protected]

Medical Appeals

Urgent: Pre-service MedicalStandard Pre-Service: MedicalPayment Denial: MedicalPayment Denial: Pharmacy 
InstructionsDetailsDetailsDetailsDetails
Contracted Treating PhysicianProvide 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 PhysicianSee 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 MedicalStandard Pre-service: MedicalPayment Denial: Medical AppealsPayment Denial: Pharmacy Appeals
Time Frame to Request AppealWithin 60 calendar days from the date on the denial noticeWithin 60 days from the date on the denial noticeWithin 60 calendar days from the date on the denial noticeWithin 60 days from the initial decision
Appeal Processing Time3 business days16 calendar daysExpedited = 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: [email protected]

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 AppealsMedical Necessity & Experimental AppealsMedical Necessity & Experimental ClaimsStandard Pre-service AppealsPayment Denial
InstructionsDetailsDetailsDetailsDetailsDetails
Member’s Contracted Treating PhysicianProvide 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 [email protected]
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 [email protected]
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 [email protected]
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 [email protected]
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 [email protected]
Member’s Non-contracted Treating PhysicianSee 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-ServiceMedical Necessity / Experimental OnlyMedical Necessity / Experimental OnlyPre-Service AppealPayment Denial: MedicalPayment Denial: Pharmacy
Time Frame to AppealWithin 180 days from the date on the denial noticeWithin 180 days from the date on the denial noticeWithin 180 days from the date on the denial noticeWithin 180 days from the date on the denial noticeWithin 180 calendar days from the date on the denial noticeWithin 180 days from the initial decision
Appeal Processing Time72 hours15 calendar daysPayment: 30 calendar days15 calendar daysExpedited = 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 [email protected]

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: [email protected] 

Medication Exceptions & Redeterminations

If your patient’s medication is not listed, you can ask us to make a medication exception to our coverage rules if they are a member of one of our plans that offer prescription drug coverage. 

Medication Exception Form

If your patient was denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Medication Redetermination Form

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