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How to Appeal a Medical Service or Payment Denial on Behalf of a Patient

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 Federal. These rules and regulations are subject to change. 

Appeal Request Forms

Appeal Request Form for Samaritan Advantage

Appeal Request Form for all Other Plans

Authorized Representative Form

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.

Processing Appeals for Members of Samaritan Advantage HMO Plans - Conventional, Premier, Premier Plus, and Special Needs

Medical Appeals

Instructions for Submitting Medical Appeals 

  Urgent: Pre-service Medical Standard: Pre-service Medical Payment Denial: Medical
Instructions Details Details Details
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 1-888-435-2396

Email: 

SHPOAppealsTeam@samhealth.org

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 Physician 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. 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: 

SHPOAppealsTeam@samhealth.org

Contracted providers: Complete the CMS 1696 Form

Non-contracted providers: Complete Waiver of Liability Form

Send email to: SHPOAppealsTeam@ samhealth.org

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 - 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: SHPOAppealsTeam@samhealth.org

Pharmacy Appeals

Instructions for Submitting Pharmacy Appeals

  Urgent: Pre-service Pharmacy Standard: Pre-service Pharmacy Payment Denial: Pharmacy
Instructions

Details

Details

Details

Contracted Treating Physicians

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: 1-888-435-2396

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: 1-888-435-2396

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: 1-888-435-2396

Email: 

SHPOAppealsTeam@samhealth.org  

Non-contracted Treating Physicians See above.  See above.  See above. 
Other Providers (non-care specific, i.e., labs, anesthesia) See above.  See above.  See above. 

Reimbursement and 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 - 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: 1-888-435-2396

Email: SHPOAppealsTeam@samhealth.org

Time Frames to Appeal and Processing Times

  Urgent: Pre-service Medical Standard: Pre-service Medical and Pharmacy Payment Denial: Medical Payment Denial: Pharmacy
Time Frame to Appeal Within 60 calendar days from the date on the denial notice Within 60 calendar days from the date on the denial notice Within 60 calendar days from the date on the denial notice Within 60 days from the initial decision
Appeal Processing Time 72 hours

Medical= 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

Processing Appeals for Members of Samaritan Choice Plan

Medical Appeals

Instructions for Submitting Medical Appeals

  Urgent: Pre-service Medical Standard: Pre-service Medical Payment Denial: Medical  Payment Denial: Pharmacy
Instructions Details Details
Details Details
Contracted Treating Physician
Provide 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 1-888-435-2396

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 Physician  See 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 and Processing Time

Urgent: Pre-Service Medical Standard Pre-service: Medical Payment Denial: Medical Payment Denial: Pharmacy
Time Frame to Appeal Within 180 days from the date on the denial notice Within 180 days from the date on the denial notice Within 180 calendar days from the date on the denial notice Within 180 days from the initial decision
Appeal Processing Time 72 hours 30 calendar days Payment: 60 calendar days

Standard = 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 - 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: SHPOAppealsTeam@samhealth.org

Processing Appeals for Members of InterCommunity Health Network CCO (IHN-CCO)

Medical Appeals

Instructions for Submitting Medical Appeals

Urgent: Pre-service Medical Standard Pre-Service: Medical Payment Denial: Medical Payment Denial: Pharmacy 
Instructions Details Details Details Details
Contracted Treating Physician  

Provide 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 1-888-435-2396

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 Physician 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. 

 Time Frames to Appeal and Processing Time

Urgent: Pre-Service Medical Standard Pre-service: Medical Payment Denial: Medical Appeals Payment Denial: Pharmacy Appeals
Time Frame to Request Appeal Within 60 calendar days from the date on the denial notice Within 60 days from the date on the denial notice Within 60 calendar days from the date on the denial notice Within 60 days from the initial decision
Appeal Processing Time 3 business days 16 calendar days

Expedited = 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 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 - 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 and Payment Denials (Medical and 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: SHPOAppealsTeam@samhealth.org

 

Processing Appeals for Members of Commercial Plans

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 for Submitting Commercial Plans Appeals

  Expedited Pre-service Appeals Medical Necessity & Experimental Appeals Medical Necessity & Experimental Claims Standard Pre-service Appeals Payment Denial
Instructions

Details

Details
Member’s Contracted Treating Physician Provide 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 1-888-435-2396

Email: SHPOAppeals Team@samhealth.org

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 1-888-435-2396

Email: SHPOAppeals Team@samhealth.org

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 1-888-435-2396

Email: SHPOAppeals Team@samhealth.org

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 Team@samhealth.org
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 Team@samhealth.org  
Member’s Non-contracted Treating Physician See 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 and Processing Time

Expedited Pre-Service  Medical Necessity / Experimental Only Medical Necessity / Experimental Only Pre-Service Appeal Payment Denial: Medical Payment Denial: Pharmacy
Time Frame to Appeal Within 180 days from the date on the denial notice Within 180 days from the date on the denial notice Within 180 days from the date on the denial notice Within 180 days from the date on the denial notice Within 180 calendar days from the date on the denial notice Within 180 days from the initial decision
Appeal Processing Time  72 hours 15 calendar days Payment: 30 calendar days 15 calendar days

Expedited = 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 1-888-435-2396

Email: SHPOAppeals Team@samhealth.org

Standard Pre-Service and 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: SHPOAppealsTeam@samhealth.org 

Medication Exceptions and Redeterminations

You can ask us to make medication exceptions and redeterminations.  

Talk with our Provider Services representatives 

call us at 541-768-5207 1-888-435-2396 8 a.m. to 6 p.m.
Mon. - Fri.