Provider News & Updates – December 2022

Referrals Recommended for IHN-CCO’s Care Management Program

InterCommunity Health Network Coordinated Care Organization Care Management Program assists members with a variety of health care needs to achieve and maintain optimal functioning. Dedicated staff work directly with members who may need a wide range of support. Intensive Care Coordination offers support services to those with more complex conditions requiring individualized case management over a longer period. 

Members can be referred to meet the needs of certain groups. Intensive Care Coordination services are available to the member populations listed below without prior approval for case management services. Examples of prioritized populations for case management are:

Priority populations for children: ages 0 to 5

  • At risk of maltreatment.
  • Show signs of social, emotional or behavioral problems.
  • Serious emotional disturbance.
  • Have neonatal abstinence syndrome.
  • May be involved with child welfare.

Priority populations for adults: 

  • Present with complex medical needs.
  • Have multiple chronic conditions.
  • Diagnosed with communication disorders.
  • Receiving Medicaid-funded long-term support services.
  • Diagnosed with HIV/AIDs and/or tuberculosis.
  • Veterans.
  • Pregnant persons.

Priority populations for behavioral health: 

  • Involved with medication-assisted treatment.
  • In need of withdrawal management.
  • IV drug use.
  • Severe persistent mental illness.
  • Persons at risk of first episode psychosis. 

If you have patients/members you would like to refer to the IHN-CCO Care Management Program, you may complete the Care Management Member Referral form and submit it via secure email to [email protected] or fax it to 541-768-9768.

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 Updates to processes will be communicated in the upcoming weeks.

2023 Brings Prior Authorization Change for Hepatitis C Diagnosis

Beginning Jan. 1, 2023, the prior authorization requirement will change for InterCommunity Health Network Coordinated Care Organization members being treated for hepatitis C. 
Prior authorization will no longer be required for hepatitis C treatment when the member has not been treated for hepatitis C in the past and is being treated with Mavyret or generic Epclusa (sofosbuvir/velpatasvir). All other requests for treatment, for example, if the member has received treatment in the past or the request is for a non-preferred medication, will continue to require prior authorization.

Although prior authorization will no longer be required for many members, case management is still available for all hepatitis C treatments regardless of treatment status. Case management can assist with an initial evaluation of barriers to adherence; coordination between patient, PCP, prescriber and pharmacy; and ensure refills are available and accessed in a timely manner. Case management can be requested by calling 541-768-9768 or emailing [email protected].

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 and click the down arrow to view the Clinical Guidelines section. There you will find medical, behavioral health and dental health guidelines.

2023 Brings Changes to Samaritan Advantage Health Plans Coverage

The following coverage changes will take effect on Jan. 1, 2023: 

Premier Plan Plus

  • Out-of-pocket maximum amount: increased from $4,600 to $4,800.
  • Outpatient hospital surgery and services: changed from 15% coinsurance to $300 copay.
  • Non-emergent transportation (Cascade West Ride Line): Increased from 12 one-way trips per year to unlimited trips.
  • Routine vision hardware benefit: increased from $125/year to $225/year.
  • Medicare-covered hearing exam: lowered from $30 copay to $25 copay.
  • Medicare-covered dental: lowered from $25 copay to $20 copay.

Premier Plan

  • Out-of-pocket maximum amount: increased from $4,600 to $5,000.
  • Outpatient hospital surgery and service: increased from $250 copay to $350 copay.
  • Ambulatory surgery center service: increased from $250 copay to $275 copay.
  • Non-emergent transportation (Cascade West Ride Line): increased from 12 one-way trips per year to unlimited trips.
  • Routine vision hardware benefit: increased from $125/year to $225/year.
  • Medicare-covered dental: lowered from $25 copay to $20 copay.

Conventional Plan

  • Out-of-pocket maximum amount: increased from $4,600 to $5,200.
  • Outpatient hospital surgery and service: increased from $200 copay to $325 copay.
  • Ambulatory surgery center service: increased from 250 copay to $300 copay.
  • Non-emergent transportation (Cascade West Ride Line): increased from 12 one-way trips per year to unlimited trips.

Special Needs Plan

  • Out-of-pocket maximum amount: increased from $3,750 to $8,300.
  • Urgently needed services: lowered maximum visit amount from $65 to $60.
  • Over-the-counter items quarterly allowance: increased from $150/quarter to $195/quarter.

Primary Care Provider Assignment Is No Longer Required 

Beginning with Jan. 1, 2023, enrollments, Samaritan Advantage members will no longer be required to have an assigned PCP on file with SHP. This does not mean that SHP will not encourage members to have a PCP, it just means SHP will not require them to have one assigned to them at the time they enroll. SHP will continue efforts to collect accurate PCP information by using claims data. This change is being made because while SHP is an HMO plan, SHP does not operate as a traditional HMO. For example, a member is not required to go through their PCP to coordinate all of their care. 

Prior Authorization Changes Are in Effect

  • Diabetic therapeutic shoes/inserts no longer require prior authorization.
  • Prior authorization is only required for magnetic resonance imaging and magnetic resonance angiography of the breast, cervical, lumbar and thoracic regions.

All skilled nursing facility stays require prior authorization (change from only stays greater than seven days requiring prior authorization).

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

Check These Important Reminders & Notices

Educational Opportunity for Providers & Staff

Harm Reduction Conference

Dec. 12 through 14, 8 a.m. to 5 p.m.

Hosted by the Confederated Tribes of Siletz Indians, this conference spotlights harm reduction approaches to health and wellness in the Indian community. Topics include discussion of active drug use, recovery, trauma, healing and other indigenous wellness topics. The goal is to create an indigenously centered conference that addresses health care in the Indian community through the medicine wheel four directions model: spiritual, mental, emotional and physical.

Free event registration through Eventbrite.
Confederated Tribes of Siletz Indians Harm Reduction Conference tickets.

Condition Code Required on Corrected & Cancelled Facility Claims

Claims billed on a CMS-1450 claim form with a bill type ending in 7 (corrected claim) or 8 (cancelled/voided claim) must be submitted with an appropriate condition code. Corrected or canceled claims that are not submitted with the appropriate condition code will be denied to the provider for the needed claim information. Please note: this CMS rule applies to claims billed to Samaritan Advantage Health Plans and IHN-CCO for dates of service effective 
Jan. 1, 2022.

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