The Utilization Management team manages authorization requests made on behalf of our members. This includes medical, surgical, mental health and addiction medicine requests for inpatient, rehabilitation, DME and other specialty services requiring an authorization for the plan.
Samaritan Health Plans will not review any retroactive requests for medical necessity unless the request meets certain exceptions outlined in our Prior Authorization FAQ (English).
Utilization management (UM) is integrated within the Medical Management care management program. This handbook is designed to assist in understanding the prior authorization review process: types of reviews performed, specific criteria applied, notification process, etc. Please access this handbook for more information and instructions for submitting online prior authorization requests. Utilization Management & Service Authorization Handbook (English).
The Utilization Management Program is designed to assure appropriate provision of services and benefits and to increase cost efficiency while improving health outcomes for members.
The primary goal of Utilization Management is to optimize member function by providing quality services in the most efficient and effective manner to members. The program provides a systematic process to promote timely access of medically appropriate care across a network of providers, treatment facilities and services through medical management, pre-service review, concurrent review and post-service review. Read about the Utilization Management Program (English).
Visit your provider portal to submit and track your authorizations online.
Samaritan Health Plans and Specialty Fusion manages authorization requests for all outpatient provider-administered specialty and oncology drugs made on behalf of members. Inpatient hospitalization and related services are exempt from review by Specialty Fusion. Please review prior authorization and drug code lists to determine if a request is necessary.
Visit the Specialty Fusion platform to submit an authorization for an outpatient provider-administered specialty or oncology drug.
Network providers may access the Specialty Fusion platform through the Provider Connect portal.
For instructions on how to navigate the Specialty Fusion prior authorization portal, please read the Specialty Fusion user guide.
Samaritan Health Plans Pharmacy Services and OptumRX manages prescription authorization requests submitted on behalf of members. Prescription drugs provided by a pharmacy may require authorization for coverage. Please review drug lists and criteria to determine if a request is necessary. Providers who supply prescription drugs in their office should buy and bill through the medical benefit.
Select medications may require prior authorization. A physician may submit authorization requests by:
You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.
Patients may need prior authorizations for some health services. The health plan uses guidelines/rules to review prior authorization requests. Guideline/rule resources can be accessed using the links below.
Specific circumstances allow a provider to appeal for a medical, pharmacy, or durable medical equipment (DME) authorization or payment denial on behalf of a patient.
Services or items requiring an authorization are identified in the plan documents and listed here by plan. Lists & Forms – Samaritan Advantage
2024 Samaritan Advantage Prior Authorization List
Part B vs D Prior Authorization Criteria
Prior Authorization Form
Prior Authorization Form Instructions
Provider FAQs for New Member Prior Authorizations
SNF/LTAC/Acute Rehab Authorization Form
FAQ Inpatient Notification Update
2024 Authorization List – Small Group Plans
FAQs for Outpatient, Physical, Occupational & Speech Therapies (for dates of service July 1 to Dec. 31, 2023)
FAQs for Outpatient, Physical, Occupational & Speech Therapies (for dates of service Jan. 1. to June 30, 2023)
Flexible Services Request Form
Flexible Services Form Instructions
2024 Prior Approval List – IHN-CCO2024 Prior Approval List – Spanish – IHN-CCO
2024 Samaritan Choice Prior Authorization List
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