Specific circumstances allow a provider to appeal a denial for medical or durable medical equipment (DME) claim on behalf of a patient. With Samaritan Health Plan Operations, our circumstances vary according to your patient's plan.

Samaritan Advantage Plan (SAHP) HMO members:

• For urgent situations: The treating provider can appeal a preauthorization denial on the patient's behalf by submitting an oral or written request directly to SAHP. This applies when the patient has not received the service and the treating provider believes that applying the standard appeal timeframe could seriously jeopardize the patient's life, health or ability to regain maximum function.
• For pre-service denials: A treating provider can appeal on the patient's behalf without being an authorized representative. This applies when the patient has not yet received the service. Medicare assumes the provider has spoken with the patient regarding the appeal.
• For post-service denials: The treating provider and the patient must complete the appropriate authorized representative form and include that form with an appeal. This applies when the patient has already received the service and the denial is related to a denied authorization. Providers can use the CMS 1696 form.

Samaritan Choice Plans/COHO/Samaritan Healthy KidsConnect/
InterCommunity Health Network:

• For urgent situations: The treating provider can appeal a preauthorization denial on the patient's behalf by submitting an oral or written request directly to the plan. This applies when the patient has not received the service and the treating provider believes that applying the standard appeal timeframe could seriously jeopardize the patient's life, health or ability to regain maximum function or the patient's pain cannot be controlled by other means.
• For pre-service and post-service denials: A treating provider can appeal on the patient's behalf with the written permission of the patient. A copy of the written permission must be received by the plan before the treating provider's appeal will be processed.

If you have questions about medical or DME appeals, please call the Samaritan Provider Hotline at (541) 768-5207 or 1-888-435-2396, Mon.-Fri., 8 a.m. to 5 p.m.