Complaints and appeals



Complaints (grievances)

Your network providers and Providence Health Assurance want to give you the best possible care. But if you have a complaint about any part of your care, you can call or write to Providence Health Assurance.


A complaint or grievance means you are not happy with something. You can make a complaint or file a grievance if:


  • You had trouble getting care.
  • You didn’t feel respected.
  • You got a bill you didn’t expect.
  • You didn’t agree with a decision Providence made.
  • You didn’t like the care you got.
  • You are unhappy with Providence.

You can file a grievance or make a complaint at any time. If you give written permission, someone else can make a complaint for you. You can make a complaint orally or in writing.



Timeframe

We will look into your complaint quickly.

  • You’ll hear back from us within 5 business days.
  • If we need more time, we’ll send you a letter to explain why.
  • You’ll get a final answer within 30 days.
  • We will not tell anyone about your complaint unless you ask us to.
  • All letters will be in the language you prefer.


If you need assistance, you can call Providence Health Assurance Customer Service at 503-574-8200 or 800-898-8174 (TTY/TDD 711).



Other options:



Below are links to the Oregon Health Authority’s complaint forms:



Appeals

If Providence says “non” to a service your doctor asked for, or stops or reduces a service, you can ask us to take a second look at the division. This is called an appeal.



What happens first?

We will send you a letter called a Notice of Adverse Benefit Determination. This letter explains:


  • What decision we made
  • Why we made it
  • How you can appeal


When to file?

You must ask for an appeal within 60 days of the date on the letter.



Who reviews your appeal?

A health care professional who understands your condition will look at your appeal.

We will send you a letter called a Notice of Appeal Resolution. You’ll get this letter:

  • As fast as we can. We will keep your health needs in mind while we look at all the facts.
  • We may need more time if we are waiting for information from your provider. We will send you a letter to let you know within 16 days after we get your appeal. We will send you a letter with our decision in 14 days. If you don’t agree with us taking the extra time, you can file a complaint.


Who can file?

You can file the appeal yourself. Or, you can give written permission for someone you trust to file it for you.



Need a fast decision?

If waiting could harm your health, you can ask for a fast appeal, also called an expedited appeal.


For fast appeals:


  • Ask your provider to write a note explaining why waiting is not safe
  • If we agree it’s urgent, we’ll call you with a decision in 72 hours
  • We may need more time if we are waiting for information from your provider. We will call you and send you a letter to let you know within 72 hours after we get your appeal. We will send you a letter with our decision in 14 days. If you don’t agree with us taking the extra time, you can file a complaint
  • If we don’t agree it’s urgent, we’ll call you and send you a letter to tell you that we will finish your appeal within 16 days. If you don’t agree with our decision not to give you a fast appeal, you can file a complaint.


What if you’re still not happy?

If we don’t finish your appeal in time, or if you don’t agree with our decision, you can ask for a fair hearing with the state. You don’t have to do this alone, someone can help you file.



How to keep getting services during an appeal:

If you got a letter saying your approved service was changed or denied, you can ask to keep getting that service while we review your appeal.

To ask for services while you wait for an appeal:


  • Call or write us within 10 days of the date on the Notice of Adverse Benefit Determination letter.
  • The request must come from you. Your provider can’t ask for you.

If we decide the original denial was correct, you may have to pay for the services you kept getting.

Please note: If your provider is contracted with Providence, they can also file an appeal with your written permission. Your provider can also support your appeal by sending us your medical records when we ask for them, or by including them with the appeal.

If your provider files an appeal on your behalf, the provider may request an administrative hearing if they do not agree with the appeal decision.

Contact us if your problem is solved at any step in this process.



Expedited appeals for urgent medical problems

If you believe your medical problem cannot wait for a regular appeal, ask PHA for an expedited (fast) appeal. You should include a statement from your provider why it is urgent. Or you can ask your provider to call us. If we agree that it is urgent we will call you with a decision within 72 hours.



Administrative hearings

If you do not agree with our decision on your appeal, you may request a hearing from the Oregon Health Authority. Your Notice of Appeal Resolution letter will have a Hearing Request form that you can mail in, to ask the state for a hearing. You can also ask Health Share/Providence Customer Service to send you a Hearing Request form, or call OHP Client Services at 800-273-0557 (TTY/TDD: 711) to ask for a form.



If you have questions about this process contact Customer Service or OHP Client Services for more information. More information is also available in your Health Share Member handbook.

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