Appeals and grievances

Filing a complaint

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. Learn more about filing an appeal or grievance in your Evidence of coverage.

Filing an appeal

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:

• Call 844-827-2355
• Fax 833-949-1888
• Submit a written request and mail to:
  Summit Health
  Attn: Medicare Appeal and Grievance Unit
  P.O. Box 820070
  Portland, OR 97282

For pharmacy appeals:

• Complete our online Prescription drug redetermination request form
• If you prefer to mail or fax your request, you may complete this prescription drug redetermination request form.

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:

• Call 844-827-2355.
• Submit a written request and fax to 833-949-1888,
  Attn: Medicare Expedited Appeal and Grievance Unit
• Submit a written request and mail to:
  Summit Health
  Attn: Medicare Appeal and Grievance Unit
  P.O. Box 820070
  Portland, OR 97282

Please make sure to write “expedited appeal” on your request.

Filing a grievance

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.

To submit your grievance, you can call us or mail your grievance to:

Summit Health
Attn: Summit Health Medicare Appeals
P.O. Box 820070
Portland, OR 97282

Appointing a representative

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.

Filing a complaint with Medicare

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.