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How to Address Complaints and Problems

Members of Samaritan Advantage Health Plan 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:

A “grievance” is the type of complaint you make if you have any type of problem with Samaritan Advantage Health Plan 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 at 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily.

You may also mail your grievance to:

Samaritan Advantage Health Plan HMO
P.O. 1310
Corvallis, OR 97339

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. If we cannot resolve your grievance over the phone, we have a formal procedure to review your grievance. Depending on the nature of the complaint, your grievance is forwarded to an Operations Manager who is responsible for investigating and resolving the matter. 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.

For quality of care problems, you may also file a grievance to Livanta. Livanta is the quality improvement organization that oversees our plan decisions. If you are concerned about the quality of care you received, including care during a hospital stay, you can file a grievance directly to Livanta:

Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
Toll Free: 1-877-588-1123
TTY: 1-855-887-6668
Fax: 1-844-420-6672

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:

  • Covering your drug even if it is not on our formulary.
  • Waiving coverage restrictions or limits on your drug.
  • Providing a higher level of coverage for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for this drug.

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:

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:

An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. 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 Plan 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.

Important information about your appeal rights

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:

  1. Expedited Requests – You can request an expedited (fast) appeal for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your appeal.

  2. Standard Requests – You can request a standard appeal for a case that involves coverage or payment for medical or prescription services. The reviewer must give you a decision within a specific timeframe as described below, depending on whether the request is for medical or prescription services.

Timeframes for a request regarding your MEDICAL BENEFITS

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.

Timeframes for a request regarding your PRESCRIPTION BENEFITS

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 7 days from the date of the request.

What do I include with my appeal?

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.

How do I request an appeal?

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 or fax your written Appeal Request Form  to Samaritan Advantage:

  • Mail:
    Samaritan Advantage Health Plan HMO
    P.O. Box 1310
    Corvallis, OR 97339
  • Fax:
    541-768-9765 (Medical Appeals)
    or
    1-844-652-7087 (Pharmacy Appeals)

If your appeal request is for a prescription drug, please address to “Part D Appeals” and send to the address above.

What happens next?

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 1-800-832-4580, daily from 8 a.m. to 8 p.m. TTY users should call 1-800-735-2900.

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 (1-800-633-4227). TTY/TTD users can call 1-877-486-2048. 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 Plan HMO, please call our Customer Service Department at 541-768-4550, 1-800-832-4580 (TTY 1-800-735-2900).

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, 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily.

Looking for Evidence of Coverage Documents?

Find them along with other plan documents.

Last modified: Oct. 20, 2016

Talk with our friendly
Medicare agents in Corvallis

call us at 541-768-4550 800-832-4580 TTY 800-735-2900 8:30 a.m. to 5 p.m.
Mon.–Fri.
or Visit our office at  2300 NW Walnut Blvd. in Corvallis 8:30 a.m. to 5 p.m., Mon.–Fri.