APPEALS AND GRIEVANCES

Grievances (Complaints)

A grievance is when you are not happy with your care, but not because of a denied service. This could be for the quality of care you received, if your rights were not respected, if you had a bad experience with office staff, etc. You can:

• Call our Customer Care team at 541-229-4842, toll free at 866-672-1551 or TTY: 541-440-6304. We are available Monday – Friday, 8am – 5pm, OR
• Fill out this form and/or write us a letter and mail it to Umpqua Health Alliance, Attn: Grievance and Appeals, 500 SE Cass Ave, Suite 101, Roseburg, OR 97470.

**Please note that dental grievances are handled by your Dental Care Organization (DCO). Please contact Advantage Dental at 866-268-9631 for more information**

We will work to resolve your complaint within five (5) business days. If you, your providers, or UHA needs more time and it benefits you, more time can be added by request. If this is the case, UHA will tell you in writing if more time is needed. We will work to resolve the issue in no longer than 30 days.

If you don’t like our answer, you can file a complaint with the Oregon Health Authority (OHA) Ombudsperson. They can be reached at (503) 947-2346, or toll- free at (877) 642-0450. The TTY number is 711. Their fax number is (503) 947-2341.

Appeals

An appeal is when you disagree with a denied service or payment. We will have sent you and your provider a letter explaining the denial. This letter is called a “Notice of Action”. You will need to file the appeal in writing with UHA no later than 60 days from the date on the denial letter we sent you. This is done by filling out the Hearing Request and Information form sent to you with your denial notice. You can also call Customer Care and start the appeal process. You will still need to send in the signed form for UHA to move forward.  If you need another form, you can call Customer Care and ask for one to be mailed to you. For more information on this process, click here.

**Standard appeal timelines will apply unless you or your provider feel that waiting will affect your life, health, or ability to attain, maintain, or regain maximum function. If this is the case you may qualify for an expedited (or fast) appeal.**

• Standard (regular) Appeals
  • We will let you know we got your appeal within five (5) business days by mail. When we make a decision, we will let you know by mail within 16 days, or as soon as your health requires.
  • We may need to take up to 14 more days, if you request it, or if we need more information that could benefit you.
• Expedited (or fast) Appeals
  • Expedited, or fast, appeals are when your life, health, or ability to attain, maintain, or regain maximum function is in trouble if you don’t receive this service. If this is the case, you can request an oral appeal over the phone by calling Customer Care. If it meets this requirement, we will let you know by phone and mail within one (1) business day that we received it. We will try to resolve appeal in no longer than 72 hours.
  • If you would benefit from more time, we will call you and tell you within two (2) calendar days to tell you why. It will take no more than 14 days to reach a decision.

When we reach a decision on your appeal we will send you a letter called a “Notice of Appeal Resolution” (NOAR). If we agree with your appeal, we will approve and pay for the service. If we do not, this letter will tell you why. We will also send you information on how to ask for a state fair hearing.

Member Hearings

You must finish the appeal process before requesting a state fair hearing with Oregon Health Authority (OHA). We tell you how to do this when you get your decision of the appeal letter, also called the “Notice of Appeal Resolution” (NOAR).  If your appeal was not in your favor, you can ask for a hearing within 120 calendar days from the date of the NOAR. You have the right to have an attorney or member representative present, and availability of free legal help through Legal Aid Services and Oregon Law Center, including the telephone number of the Public Benefits Hotline 1-800-520-5292, TTY711.

You will need to fill out this form or you can call Customer Care and ask for one to be mailed to you. Want more information on your hearing rights? Click here.

Forms and Member Materials

• UHA Complaint Form
• OHA Complaint Form
• Appeals and Hearings Flowchart
• Appeal and Hearing Request | (Spanish)
• Hearing Rights | (Spanish)
• Notice of Action Benefit Denial (NOABD) FAQ’s
• Member Handbook
• CE01 – Grievance Appeals and Hearings
• CE21 – Adverse Benefit Determinations

If you need help filling out forms, need the notice in another language, large print, Braille, CD, tape or another format, or need an interpreter, call Customer Care at 541-229-4842; Toll Free: 866-672-1551; TTY: 541-440-6304 or 711, Monday to Friday 8am to 5pm.

Contact Us

Phone: Customer Care (M-F; 8AM – 5PM) 541-229-4842/Toll Free: 866-672-1551/ TTY: 541-440-6304
Email: UHAGrievance@umpquahealth.com
By mail:
UHA A & G
500 Cass Ave., Suite 101
Roseburg, OR 97470