If you have a problem or complaint (grievances, coverage decisions, appeals), please call us first. Your health and satisfaction are important to us. When you have a problem or concern, we hope you’ll try an informal approach first: please call Member Services at (503) 345-5702 or (866) 798-2273. We will work with you to try to find a satisfactory solution to your problem.

Refer to the How to sections below.

How to file a Grievance

Grievances or complaints about quality of care, waiting times and the Member services you receive are examples of the kinds of problems handled through this process. Calling Member Services is the first step or you may put your complaint in writing and send it to us.

You will find information about Grievances in Chapter 9 of your Evidence of Coverage.
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How to File a Coverage Decision or an Exception

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 drugs. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please call Member Services at (503) 345-5702 or (866) 798-2273 or contact us in writing.

You will also find information about Coverage Decisions and Exceptions in Chapter 9 of your Evidence of Coverage.
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How to File an Appeal:

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

You can contact us in writing or by phone to make a complaint or an appeal. To contact us by telephone, call Member Services, Monday through Friday from 8 am to 8 pm toll-free at (503) 345-5702 or (866) 798-2273, TTY (800) 735-2900.

You will also find information about Appeals in Chapter 9 of your Evidence of Coverage.
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Quality Improvement Organization

There is a Quality Improvement Organization in each state. In Oregon the Quality Improvement Organization is called Acumentra Health.

Acumentra Health has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare.

You should contact Acumentra Health if you have a complaint about the quality of care you have received, or you think coverage for your hospital stay, home health care, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility (CORF) is ending too soon.

You can contact Acumentra Health at (503) 279-0100 or in writing at 2020 SW Fourth Avenue, Suite 520, Portland, OR 97201.