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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 or durable medical equipment (DME) authorization or payment denial on behalf of a patient. With Samaritan Health Plans or InterCommunity Health Plans, the circumstances vary according to the patient’s plan.

Appeal Form for All Plans
Authorized Representative Form for All Plans

Samaritan Advantage HMO Plans - Conventional, Premier, Premier Plus, and Special Needs

For Urgent Situations

Any physician can appeal a pre-service denial on their patient’s behalf by submitting an oral or written request directly to Samaritan Health Plans. 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.

For Standard Pre-Service Denials

Only the treating physician can appeal on the patient’s behalf without being an authorized representative. 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.

For Payment Denials

Any contracted provider can appeal on the patient’s behalf. An authorized representative form must accompany the appeal. Both the patient (or authorized representative) and the contracted provider must complete their applicable sections of the form.

  •  You may use Medicare’s authorized representative form, CMS 1696 Form, in place of Samaritan Health Plan’s authorized representative form.

Any non-contracted provider can appeal a denied payment but only after completing a waiver of liability. Send the form, the appeal request and any supporting documentation to SHPO to the attention of the Appeal Team.

Waiver of Liability Form

Please mail your form to:
Samaritan Health Plans, PO Box 1310, Corvallis, OR 97339

 

 For Urgent Situations

Any physician can appeal a pre-service denial on their patient’s behalf by submitting an oral or written request directly to Samaritan Health Plans or InterCommunity Health Plans. 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 (for Samaritan Choice Plans only) the patient’s pain cannot be controlled by means other than by the service that was denied.

For Standard Pre-Service and Payment Denials

A provider can appeal on the patient’s behalf 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 Samaritan Health Plans or InterCommunity Health Plans before the provider’s appeal will be processed.

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.