If you have concerns or problems with any part of your benefits, care, service or prescription drugs; you can file a complaint. Appeals and grievances are the two types of complaints you can file.
If you do not agree with a decision we have made, you can make an appeal (a request to change the decision). You can do this for decisions about services and payment. You can also request that we cover an item or service that is not in your plan. If you need to ask for a review of a medical care coverage decision made by our plan, you or your provider may do one of the following:
For pharmacy appeals:
Learn more about making a pharmacy appeal in your Evidence of Coverage.
If your health requires a quick response, you must ask for a “fast appeal.” For an expedited appeal, you or your provider may do one of the following:
Please make sure to write “expedited appeal” on your request.
Learn more about making an appeal in your Evidence of Coverage.
If you are not satisfied with us or one of our providers, you can file a grievance. A grievance is not for coverage or payment. Learn more about filing a grievance in your Evidence of coverage.
Need help filing an appeal or grievance? Please call Summit Health Member Services at 844-827-2355. TTY users, dial 711. Member Services is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from Oct. 1 to March 31. After March 31, your call will be handled by our automated phone system on weekends and holidays. Weekend calls are forwarded to voicemail and returned the next day. You can also find out how many appeals, grievances and exceptions we have received. Just ask us.
If you choose to mail your grievance, send it to:
Attn: Summit Health Medicare Appeals
P.O. Box 820070
Portland, OR 97282
You can assign someone you trust to request authorization, or file a claim, grievance or appeal. To do this, please complete our Appointment of Representative form. You will need to have the person you appoint sign the form. You can submit this form with your appeal or grievance request.
We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online complaint form.
Last updated Oct. 1, 2022