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Coverage Decisions, Appeals, and Grievances

COVERAGE DECISIONS

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or prescription drugs. As a member of one of our plans, you have the right to ask for coverage of a medical service or prescription drug. This can include those services or prescription drugs that we must approve in advance (also called a "prior authorization"), or when you're asking us to allow an exception for a service or drug that is not normally covered.

Organization Determinations

When a coverage decision involves a medical service, it is called an Organization Determination. An Organization Determination may be requested by you, your appointed representative*, or your provider in the following ways:

  • By calling Customer Service toll free at 877-672-8620. You may also use this number to check on the status of an existing request.
  • By completing a Prior Authorization form and mailing or faxing the completed form back to us.


*To appoint a representative for coverage decisions, please complete the CMS Appointment of Representative Form (CMS Form-1696) and include a signed copy with your request. The appointment is valid for one year unless revoked.

Coverage Determinations

When a coverage decision involves prescription drugs, it is called a Coverage Determination. If a prescription drug is not covered, or if there are other limits or restrictions on a drug, you can ask us to make a coverage determination. A Coverage Determination may be requested by you, your appointed representative*, or your provider in the following ways:

  • ATRIO Health Plans
  • 2965 Ryan Drive
  • Salem, OR 97301
  • Fax: 541-672-8670

*To appoint a representative for coverage decisions, please complete the CMS Appointment of Representative Form (CMS Form-1696) and include a signed copy with your request. The appointment is valid for one year unless revoked.

Prescription Drug (Part D) Information

APPEALS AND GRIEVANCES INFORMATION

Appeals

As a member, you have the right to file an appeal when you want us to re-evaluate and change a decision we have made about what benefits are covered for you or what we will pay for a benefit. Your appeal must be filed within 60 calendar days from the date on the denial letter you received. In some situations, we may accept your appeal beyond 60 days if you show good cause for an extension.

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.

An appeal may be filed by you or your appointed representative** in the following ways:

By calling Customer Service toll free at 877-672-8620. You may also use this number to check on the status of an existing appeal.

By completing the Online Appeal Request Form. Note: To protect your personal health information, your appeal and attachments are sent to Appeals@atriohp.com using secure (encrypted) email.

By completing an Appeal Request Form and mailing or faxing the completed form back to us.

  • ATRIO Health Plans
  • 2965 Ryan Drive SE
  • Salem, OR 97301
  • Fax: 866-339-8751

**To appoint a representative for appeals, please complete the CMS Appointment of Representative Form (CMS Form-1696) and include a signed copy with your appeal. The appointment is valid for one year unless revoked.

Grievances

A grievance is any complaint, other than one that involves a request for a coverage determination or an appeal. Examples of a grievance include a complaint about quality of care, waiting times, or the customer service you receive. The grievance must be submitted within 60 days of the event or incident. ATRIO 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.

A grievance may be filed by your or your representative* in the following ways:

  • By calling Customer Service toll free at 877-672-8620. One of our representatives will try to resolve your complaint over the phone. You may also use this number to check on the status of an existing grievance.
  • By completing the Grievance Request Form and mailing or faxing the completed form back to us.
  • ATRIO Health Plans
  • 2965 Ryan Drive SE
  • Salem, OR 97301
  • Fax: 866-339-8751

*To appoint a representative, please complete the ATRIO Health Plans Authorized Representative Form

Members can also file a complaint directly with Medicare by going to Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048. (By selecting this link you are leaving ATRIO Health Plans' website)

To obtain an aggregate number of ATRIO Health Plan's grievances, appeals and exceptions, please call Customer Service at 877-672-8620.