APPEALS AND GRIEVANCES

Umpqua Health Alliance (UHA) cares about you and your health. UHA and our providers will not stop you from filing a complaint, appeal or hearing. If you tell us your concerns, we will not punish you. We will not take away your coverage (disenrollment) or your provider. Our team will look into each of your concerns and keep them private. We will try to find a solution.

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.

Grievances, Appeals, and Hearings

You, your provider, or someone you choose, with your written consent, can file a grievance (complaint), appeal, or hearing for you. You can ask for a copy of the paperwork used to make the decision at any time, free of charge. We will provide you with help to complete forms and other steps needed to file a grievance (complaint), appeal, or hearing. This could be:

Help from a qualified community health worker (i.e. peer specialist or personal navigator) or care coordination services.
Interpreter services or auxiliary (added help or support) aids and services.
A letter in a different language or format.
Explaining the grievance (complaint), appeals, and hearings process or providing policies or documents.

We can also give you more information about how we handle grievances and appeals. Copies of our notice template are also available. If you need help contact us by phone, mail, or email.

Call our Customer Care team

Monday – Friday, 8:00AM – 5:00PM Phone: 541-229-4842 Toll free: 866-672-1551 TTY: 541-440-6304

Write or email

Attn: Grievance and Appeals, 3031 NE Stephens Street, Roseburg, OR 97470

UHAGrievance@umpquahealth.com

Call OHP Client Services Unit (CSU)

800-273-0557

Call OHA’s Ombudsperson

503-947-2346 or toll free at 877-642 -0450

Grievances (Complaints)

If you are unhappy with your care you can file a complaint unless it is about a denied service. For example, if you feel you were not treated with respect or did not receive the quality of care you deserve. We will try to get all the facts about the issues. We will ask you to send us any information you have. We will also reach out to others that are a part of the complaint. We will try to solve your issue within five (5) working days. If we need more information or time to look into your issue, or you ask us for more time, we will tell you in a letter. We will then resolve the complaint within 30 days. We will try to reach you with the resolution by phone and mail. If you are not happy with how we handled your grievance, you can contact the OHP Client services, or an OHA Ombudsperson at the numbers above.

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

Appeals

If we deny, stop, or reduce a medical service your provider has ordered, we will send you a written Denial of Service Request explaining why we made that decision. This notice is also known as a Notice of Adverse Benefit Determination. This is not a bill for you to pay. We will also let your provider know about our decision. If your provider tells you that a service is not covered or that you will have to pay for a service, you can contact us and ask for a Denial-of-Service Request. Once you have the notice, you can request an appeal.

Requesting an Appeal

If you disagree with our decision and would like us to change it, you can request an appeal. You have a right to request an appeal. If you have a representative, they may request an appeal for you with your written permission. Your provider may also appeal our decision if you give them permission in writing to do so. An appeal request can be made either orally or in writing. To request an appeal call us at the number below. Or you can complete and send us the Request to Review a Healthcare Decision form (OHP 3302) attached to the original notice by mail or fax. If you have questions, you can also email us at UHAGrievance@umpquahealth.com.

Appeal Review

Once we get your appeal request, we will look at the original decision. A new doctor will look at your medical records and the service request to see if we followed the rules correctly. You can provide any more information you think would help us make our decision. Once that review is done, we will send you our decision notice in writing. This notice is called a Notice of Appeal Resolution. We will also attach a hearing request form in case you do not agree with the outcome.

Appeal Timeframes

You have 60 days from the date on the Denial-of-Service notice to file an appeal. Once we get your request, we have 16 days to make our decision for a standard appeal. If you need more time, or if we need more time to make a decision, we can extend the timeframe by 14 days. If we extend the timeframe, we will do our best to let you know orally. We will always send a written notice to let you know why we needed more time. You have a right to file a grievance if you disagree with the extension.

Fast or “Expedited” Appeals & Timeframes

A fast or “expedited” appeal can be requested if you or your provider thinks that waiting for a standard appeal could seriously harm you. If you qualify for a fast appeal, we will make our decision as quickly as your health requires. We will take no more than 72 hours from the time we receive your appeal request. We will do our best to reach you and your provider by phone to let you know our decision. We will always send our decision in writing. If we need more information and it is in your best interest, we can extend the timeframe by up to 14 days. If we extend the timeframe, we will do our best to let you know by phone. We will always send a letter to let you know why we need more time. You have a right to file a grievance if you disagree with the extension.

Contested Case Hearings

If you disagree with our appeal decision or we went beyond the required timeframes to make our decision you can request a hearing with an Oregon Administrative Law Judge. It is your right to request a hearing. At the hearing, you can tell the judge why you do not agree with our decision about your appeal. The judge will make the final determination. Your representative, if you have one, or the provider who initially requested the appeal may also request a hearing on your behalf if they have your permission in writing.

Contested Case Hearing Timeframes

You have 120 days from the date on the Notice of Appeal Resolution to request a hearing. To request a hearing send the Request to Review a Healthcare Decision form (OHP 3302) to the notice we sent you to: OHA-Medical Hearings 500 Summer St NE E49 Salem, OR 97301 Fax: 503-945-6035.

Request to Review a Healthcare Decision form (OHP 3302) | (Spanish)

Fast or “Expedited” Hearings

The hearings process takes time. If you need a fast or “expedited” hearing because waiting for a standard hearing could seriously harm you, be sure to note that on the Request to Review a Healthcare Decision form (OHP 3302). The Oregon Health Authority’s Medical Hearings Unit will review your request for an expedited hearing. If the request is denied, you will get a letter within two days to let you know. Representation in a Hearing You have the right to have another person of your choosing represent you in the hearing, for example a friend, family member, lawyer, or your medical provider. You also have the right to represent yourself if you choose. If you hire a lawyer, you must pay their fees. For advice and possible no-cost representation, call the Public Benefits Hotline at 1-800-520-5292; TTY 711 (a partnership between Legal Aid of Oregon and Oregon Law Center). Information about free legal help can also be found at www.OregonLawHelp.com.

Continuation of Benefits & Services

If we close or reduce a service or benefit you were already receiving, you can keep getting the full benefit during the appeal and hearings process. You have to let us know that you want the full service or benefit to continue when you request the appeal or hearing. You have 10 days from the date of the Notice of Adverse Benefit Determination or the Notice of Appeal Resolution letter to request that your benefits continue. If our decision is upheld in the appeal or hearing process, you may need to pay for the service or benefit you received during that time. If our decision is reversed in the appeal or hearing, and you kept getting the benefit during that time, we will go back and pay for it. If our decision is reversed in the appeal or hearing and you were not receiving the service or benefit, we will approve or provide the service or benefit as quickly as your health requires. We will take no more than 72 hours from the day we get notice that our decision was reversed.

Peer-to-Peer Meeting

In some cases, if your provider asked UHA to cover a service or supply that was denied, they can ask for a peer-to-peer meeting. This means they can ask to talk to our Medical Director about the denial. If fitting, UHA will schedule a time to talk. You may still file an appeal while your doctor works on this.