Provider News & Updates – December 2022

Contracted Behavioral Health Providers to See Payment Increases

Effective Jan. 1, 2023, the Oregon Health Authority will implement a managed care-directed payment arrangement that will provide a uniform percentage increase payment to qualified network contracted behavioral health providers for services delivered during the contract year. The increase will be in addition to the contracted rates CCOs had in place for qualified behavioral health providers effective Jan. 1, 2022. 

The four behavioral health-directed payments will further the goals and priorities of the Medicaid program as follows:

• Tiered uniform rate increase.
• Co-occurring disorder-directed payment.
• Culturally and linguistically specific service-directed payment.
• Minimum fee schedule directed payment.

For more information on qualifying for these payments and/or how to work with IHN-CCO to gather required documentation, please visit samhealthplans.org/Providers. Updates to processes will be communicated in the upcoming weeks.

Clinical Practice Guidelines Updated & Adopted for Recommended Screenings, Asthma & Obesity

The Clinical Practice Guidelines are meant to assist providers in making decisions about appropriate health care for specific clinical circumstances. They are also intended to improve the quality and consistency of care provided to members. Each SHP CPG is endorsed by a physician champion and adopted by SHP’s Quality Management Council.

The SHP Quality Management Council recently adopted the updated:  

• Recommended Pediatric Preventive Screening Guideline. 
• Asthma Guideline. 
• Obesity Guideline. 

To review all CPGs please visit the samhealthplans.org/ClinicalGuidelines and click the down arrow to view the Clinical Guidelines section. There you will find medical, behavioral health and dental health guidelines.

Utilization Management Policy & Procedure Changes Are in Effect

Effective Nov. 1, the following changes were made to Utilization Management policies and procedures:

• Requests for expedited determination:
  • Authorization requests must indicate that waiting for a decision within the standard timeframe could place the member’s life, health or ability to regain maximum function in serious jeopardy.  
  • Expedited status may be denied and the request processed as standard, when clinical documentation does not support the need to expedite.
• Retroactive review:
  • Samaritan Health Plans follows state and federal regulations and contract language for review of retroactive authorization requests. Retroactive requests are reviewed only for the extenuating circumstances listed below. If the exceptions are met, retroactive requests are processed according to the specific line of business standard timeframe. If the exceptions are not met, the request will be denied.
  • The timeframe for acceptance of retroactive requests for authorization:
    • Samaritan Advantage Health Plans, Samaritan Choice Plans and Employer Group Plans: Physical and behavioral health retroactive requests will only be considered within 30 calendar days from the date the service was rendered.
    • InterCommunity Health Network Coordinated Care Organization: Physical and behavioral health retroactive requests will be considered up to 90 calendar days from the date the service was rendered. Any requests for authorization after 90 days from date of service require documentation from the provider demonstrating the specific reason why authorization could not have been obtained within 90 days of the date of service.
  • Exceptions:
    • The member indicated at the time of service that they were self-pay or no coverage was in place.
    • A natural disaster prevented the provider or facility from securing prior authorization or providing hospital admission notification.
    • Provider presents compelling evidence of an attempt to obtain prior authorization in advance of the service. The evidence shall support the provider followed SHP policy and that the required information was entered correctly by the provider office into the appropriate system.
    • Member enrollment was entered retroactively in Facets and was not available at the time of service for the provider to obtain prior authorization from SHP.
    • Requested within seven calendar days of service for detoxification related to substance use, an initial outpatient mental health evaluation, day treatment, psychiatric residential treatment and subacute care.
• Peer-to-peer consultation:
  • Treating providers may request a peer-to-peer conversation with SHP Medical Review to discuss the reason(s) for a specific denial or adverse benefit determination of services or items. A peer-to-peer is not intended to overturn a previously denied authorization request; a peer-to-peer discussion takes place after an adverse benefit denial has occurred. The discussion gives the requesting provider the opportunity to discuss the case and criteria for approval with the SHP medical director who issued the denial. Providers have five business days after the issuance of a denial letter to request a peer-to-peer.

Current policies and procedures may be requested by calling SHP Customer Service at 541-768-4550 or 800-832-4580 (TTY 800-735-2900).

An exciting new change is coming for the review of medications administered in facilities or the provider’s office (provider-administered drugs). Prior authorizations for medications listed on the prior authorization lists will soon be completed by a pharmacist in SHP’s Pharmacy Department. There may be changes to the review process once the authorization is received. This is anticipated to be a beneficial change for members and will streamline the review process. Updates will be provided as this process develops. 

Prior authorization lists may be found on the Providers webpage at samhealthplans.org/Authorizations.