Medical appeals, determination and grievance processes

If you have a concern or are having a problem as a Providence Medicare Advantage Plans member, there are three types of processes (organization determinations, appeals and grievances) to follow depending on the nature of the issue. The information below will help you determine the best way to proceed.

How do I find out more information about my plan's grievance, determination and appeals process?

If you have prescription drug coverage please refer to chapter nine of your plan's evidence of coverage  (EOC) for more information regarding grievance, determination and appeals processes. If you do not have prescription drug coverage please refer to chapter seven of  your plan's evidence of coverage  (EOC) for more information regarding grievance, determination and appeals processes.

You may contact customer service with any questions or concerns including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with Providence Medicare Advantage Plans.

What is an organization determination and when do I use it?

An  organization determination  is also called a "coverage decision." An organization determination is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making an organization determination anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider - and perhaps change - this decision by making an appeal.

To request an organization determination you, your doctor, or your representative may:

  • Call: 503-574-8000 or toll free 1-800-603-2340
  • TTY/TDD: 711
    (This number requires special telephone equipment)
  • Fax: 503-574-8757 or 1-800-396-4778
  • Write: Providence Medicare Advantage Plans
    PO Box 4158
    Portland, OR 97208-4158

What is an appeal and when do I use it?

If we make a coverage decision and you are not satisfied with our decision or part of our decision, you or your representative can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal."

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the benefits properly. When we have completed the review we will give you our decision in writing.

If we say no to all or part of your Level 1 Appeal, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. These additional levels are explained in your member handbook/evidence of coverage.

To file an appeal you or your representative may:

  • Call: 503-574-8000 or toll free 1-800-603-2340
  • TTY/TDD: 711
    (This number requires special telephone equipment)
  • Fax: 503-574-8757 or 1-800-396-4778
  • Write: Providence Medicare Advantage Plans
    Attn: Appeals and Grievances Department
    PO Box 4158
    Portland, OR 97208-4158

What is a grievance and when do I use it?

A  grievance  is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your member handbook/evidence of coverage.

If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 503-574-8000 or 1-800-603-2340 (TTY line at 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Providence Medicare Advantage Plans Grievance Procedure.

To use the formal grievance procedure, you may submit your written grievance to the Providence Appeals and Grievance Department. If you file a written grievance, or your complaint is related to quality of care and we have your consent to investigate, we will respond in writing to you. 

You may request an expedited grievance if you disagree with our decision to:

  • Not grant you an expedited appeal.
  • Not grant you an expedited determination.
  • Extend the standard review period of an initial decision or appeal.

We will promptly acknowledge that we received your expedited or "fast grievance" within 24 hours. A resolution to your grievance will be accomplished in the timeliest manner but no more than 72 hours from the time of our receipt. The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

To file a grievance you or your representative may:

  • Call: 503-574-8000 or toll free 1-800-603-2340
  • TTY/TDD: 711
    (This number requires special telephone equipment)
  • Fax: 503-574-8757 or 1-800-396-4778
  • Write: Providence Medicare Advantage Plans
    Attn: Appeals and Grievances Department
    PO Box 4158
    Portland, OR 97208-4158

For quality of care problems, you may also complain to the quality improvement organization (QIO)

You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. Please refer to Chapter 2, Section 4, of your member handbook/evidence of coverage for additional information about the Quality Improvement Organization in your state.

Quality review organizations

The Centers for Medicare & Medicaid Services (CMS) has changed the national Quality Improvement Organization (QIO) Program, separating medical case review from quality improvement work. Beginning August 1, 2014, QIO work will be carried out in each state under two types of regional contracts:

Medical case review will be performed by Beneficiary and Family Centered Care QIOs (BFCC-QIOs). Livanta, LLC is the point of contact for  Member Appeals  for the states of Oregon and Washington.

  • Livanta, LLC
    Phone: 1-877-588-1123
    Fax (appeals): 1-855-694-2929
    Fax (all other review types): 1-844-420-6672

Mailing Address:
Livanta, LLC - BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

Medicare complaint form

If you have complaints or concerns about Providence Medicare Advantage Plans and would like to contact Medicare directly please complete the CMS complaint form.

The Medicare Beneficiary Ombudsman

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances and information requests.

Appointing a representative

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call customer service. If you are requesting Part C medical care or services, this statement must be sent to us at the address or fax number listed under "Part C Organization Determinations."

  • If you would prefer that someone else act on your behalf, please complete the CMS appointment of representative form (PDF), sign it and return it to us.
    • Call - if it is a fast appeal: 503-574-8000 or toll free 1-800-603-2340 (TTY: 711), M-Sun, 8 a.m. to 8 p.m.
    • Fax: 503-574-8757 or 1-800-396-4778
    • Write: Providence Medicare Advantage Plans
      Attn: Appeals and Grievances Department
      PO Box 4158
      Portland, OR 97208-4158
    • In person: Providence Medicare Advantage Plans
      Attn: Appeals and Grievance Department
      3601 SW Murray Blvd., Suite 10
      Beaverton, OR 97005
  • Non appeal-payment determinations require a CMS appointment of representative form (PDF) if someone other than the enrollee is submitting a member reimbursement on the enrollee's behalf.
    • Write: Providence Medicare Advantage Plans
      Attn: Medicare Advantage Claims
      PO Box 3125
      Portland, OR 97208-3125