Provider News & Updates – March 2023

IHN-CCO Revises Requirements for Outpatient Rehab Services

InterCommunity Health Network Coordinated Care Organization made several retroactive changes to the original 2023 prior authorization requirements for physical, occupational and speech therapy, and cardiac and pulmonary rehabilitation. Effective for services beginning Jan. 1, 2023, prior authorization requirements have been updated to the following:

  • Physical, occupational and speech therapy:
    • Authorization is not required for an initial therapy evaluation and the first 10 visits.
    • Authorization will be required for 11 or more visits, beginning on the 11th visit.
    • Authorization requirements apply for the calendar year, per therapy type.
  • Cardiac and pulmonary rehabilitation:
    • Authorization is not required for the first 30 visits.
    • Authorization will be required for 31 or more visits, beginning on the 31st visit.
    • Authorization requirements apply for the calendar year, per rehabilitation type.

When submitting prior authorization requests for either physical or occupational therapy, please be mindful of time units for billing. Authorizations for PT/OT must be requested in units, not visits. One (1) visit equals four (4) units.

The retro-authorization time frame for IHN-CCO is 90 days. All retro-authorization requests for these services will be given full consideration during this transition period, including requests with both retrospective and future visits.

New Policy Allows Reimbursement During Provider Credentialing Period

Effective Jan. 1, 2023, services provided to Samaritan Health Plans and InterCommunity Health Network Coordinated Care Organization members during the provider credentialing review period are eligible for reimbursement once credentialing has been approved. SHP’s new policy allows for providers to treat SHP/IHN-CCO members during the credentialing period to increase access to care and reduce wait times for members to be seen.

Eligibility for claims reimbursement begins either the date a completed credentialing application is received by the SHP Credentialing Department or the effective date of the provider’s contract with SHP/IHN-CCO, whichever is later. However, claims for dates of service during the credentialing period should be submitted only after the provider’s credentialing is fully approved. Claims submitted with receipt dates prior to the provider being fully credentialed will continue to be denied. To avoid claims resubmission and reprocessing, please pause billing until credentialing is approved.

If a provider’s credentialing application is denied or there is no contract in effect between the provider and SHP/IHN-CCO on the date of service, the services will be considered out-of-network and will be processed according to plan benefits and out-of-network authorization requirements.

Care Management Services Available for Patients & Their Providers

Samaritan Health Plans understands the challenges you face with helping your patients with chronic conditions and is here to support you.

SHP care management services are offered as a supplemental resource to the provider care team to assist in serving members who have special health care needs, such as complex behavioral, medical and oral health conditions, and social determinants of health barriers. Care management services are designed to engage members, their families and caregivers to meet your patients’ care needs and goals, and to promote continuity of care and effective use of resources. Care management services are voluntary and provided at no cost to eligible members of Samaritan Health Plans’ Medicare Advantage and InterCommunity Health Network Coordinated Care Organization Medicaid plans.

SHP has decided to end its care management partnership with Sagility (formerly AxisPoint Health), which provided the Care Together program. Effective April 2023, Samaritan Health Plans’ Integrated Care Coordination team will begin providing care management services to SHP members that you serve.

No action is required from you at this time. If you have any questions about SHP Integrated Care Coordination Services, please contact SHP at 800-832-4580. To make a referral, please visit Care Management Resources (see Case Management Services drop-down menu), complete a Case Management Member Referral form and submit a referral via fax at 541-768-9768 or send a secure email to carecoordinationteam@samhealth.org.

Samaritan Advantage Health Plans to Launch Rewards & Incentives Program

Samaritan Health Plans will soon launch a Rewards and Incentives Program. This program is available to all Samaritan Advantage Plans members who receive their recommended annual preventive screenings. The program launch is planned for April 1 and rewards will be granted to members for all 2023 visits through December 31. Upon SHP’s receipt of a claim for an initial qualifying service, the member will be mailed a reusable debit card loaded with their earned monetary rewards. Additional qualifying services will have applicable rewards automatically added to the member’s card. Members can use the rewards card to make purchases at various community retailers including grocers, pharmacies, home improvement supply stores and many others. This program is offered as a continuation of our partnership with Employee Benefits Corporation (EBC) which administers the Samaritan Advantage member Benefits MasterCard.

Members will receive rewards in the amounts shown for the following preventive services:

  • Health risk assessment completion:
    • $25 reward (1 per calendar year).
  • Annual Wellness Visit/Annual Physical Exam/Welcome to Medicare Visit:
    • $25 reward (1 per calendar year).
    • CPT/HCPC codes: 99381-99397, 99429, G0402, G0438, G0439, G0468.
  • Bone density measurement test:
    • $20 reward (1 per calendar year).
    • CPT/HCPC codes: 76977, 77078, 77080, 77081, 77085, 77086, G0130.
  • Breast cancer screening:
    • $20 reward (1 per calendar year).
    • CPT/HCPC codes: 77063, 77067, G0202.
  • Cervical cancer screening:
    • $20 reward (1 per calendar year).
    • CPT/HCPC codes: G0476, G0101, G0123, G0124, G0141-G0148, 87623-87625, 88141-88143, 88147-88155, 88164-88167, 88174, 88175.
  • Colorectal cancer screening:
    • $20 reward (1 per calendar year).
    • CPT/HCPC codes: G0104, G0105, G0106, G0120, G0121, G0122, G0327, G0328, G6025, S0601, 00811, 00812, 44388-44394, 44401-44408, 44799, 45330-45346, 45378-45385, 45388-45389, 45399, 81528, 82270-82274, 88304, 88305.
  • Diabetes screening:
    • $10 reward (2 per calendar year).
    • CPT/HCPC codes: 82947, 82950, 82951, 82952, 83036.
  • Flu vaccination:
    • $25 reward (1 per calendar year).
    • CPT/HCPC codes: 90662, 90672, 90674, 90682, 90685, 90686, 90687, 90688, 90694, 90756, Q2039.
  • Glaucoma screening:
    • $10 reward (1 per calendar year).
    • CPT/HCPC codes: G0117, G0118.
  • Prostate cancer screening:
    • $20 reward (1 per calendar year).
    • CPT/HCPC codes: G0102, G0103.

Additional information will be provided prior to the April 1 launch date. Questions or concerns about the program can be directed to the Medicare Programs team at SHPMedicarePrograms@samhealth.org.

OHA Mandates Updated Credentialing & Re-credentialing Applications

Effective April 23, Oregon Health Authority will mandate the 2021 version of its credentialing and re-credentialing applications for all providers in Oregon. All credentialing entities will be required to accept the mandated 2021 applications only, and all outdated versions of these OHA applications will be rejected after April 23. 

Completed applications should continue to be sent directly to the organization from which credentialing or re-credentialing is being requested. Do not send completed applications directly to OHA. For confidentiality reasons, applications will not be forwarded and will be shredded by OHA.

Providers can access the mandated 2021 application forms by visiting the Advisory Committee on Physician Credentialing Information portion of OHA’s website at Oregon.gov.

Claims & Billing Tips to Improve Efficiency

Electronic Tertiary Billing Now Accepted

Effective Jan. 13, 2023, claims for coordination of benefits in the tertiary position are now accepted electronically. For prompt reimbursement, please include all relevant EOB data from both the primary and secondary payers.

Claims for Evaluation & Management Codes with Vaccinations
Practitioner evaluation and management office visits that include the administration of one or more vaccinations should be billed on a single claim when performed together on the same date of service. Services split into two or more claims will process with a “clinical edit” and disallow full reimbursement. Please bill modifiers, as appropriate, based on established coding guidelines. By billing these services together, both the provider and Samaritan Health Plans can avoid the additional administrative costs and reprocessing time associated with corrected claim submissions.

Check These Important Reminders & Notices

Quarterly Provider Webinar to Be Held in Early March

Attend one of the Samaritan Health Plans quarterly provider webinars to receive provider-related updates and information from SHP and IHN-CCO. If you would like to attend but did not receive an invitation, please email shpprovider@samhealth.org for an invite to the current session. To ensure receipt of future webinar invitations, please sign up for Provider News at the bottom of this page.

When: March 8, 1 to 2 p.m., or March 9, 10 to 11 a.m.

Where: Virtual Teams Meeting

New Contact Information for Pharmacy Prior Authorizations

Samaritan Health Plans has implemented new fax numbers for pharmacy authorization requests. All requests for pharmacy prior authorizations should be submitted to the new fax numbers below, specific to each separate line of business.

InterCommunity Health Network-CCOFax: 844-611-3831
Samaritan Advantage Health PlansFax: 844-403-1028
Employer Group Plans/Samaritan Choice PlansFax: 844-403-1029

Providers utilizing the electronic prior authorization submission site, CoverMyMeds, for Samaritan Advantage Plans or Employer Group Plans, may see the OptumRX logo in the form name. This is expected and the form will be received by the SHP delegate, OptumRX, for review.

Sterilization Consent Forms Required for InterCommunity Health Network Members
Oregon law requires informed consent to be obtained from any IHN-CCO member who requests voluntary sterilization or a hysterectomy. Without proper consent, it is prohibited to use state or federal dollars to perform these services. The Oregon Health Authority has specific online forms that must be completed at least 30 days, but no more than 180 days, prior to the procedure. IHN-CCO is required to submit consent forms to OHA for any sterilization or hysterectomy claims received. If the consent form is incomplete and/or not included with the claim submission, claims for sterilization will be denied. To assist you with completing this, please follow these tips:

  • All fields must be complete and legible.
  • Member signatures on the consent form should be collected at least 30 days, but no more than 180 days, prior to the procedure. Electronic signatures are not allowed.
  • Any interpreter’s statement must be signed and dated the same day as the member’s signature.
  • The statement of the person collecting the consent must be signed and dated the same day as the member’s signature.
  • The physician’s signature must be dated on the date of the procedure.
  • The consent form must be included with the claim submission for reimbursement.

Sterilization forms can be found on OHA’s website in English and Spanish. 

EBC Benefits MasterCard Covers Supplemental Benefits Only

The Employee Benefits Corporation (EBC) Benefits MasterCard provided to Samaritan Advantage members is for coverage of supplemental benefits only. Providers should not be asking for or processing a member’s EBC card to cover copays or to make payments on services that are covered by Medicare.

Supplemental benefits eligible for payment using the EBC card include:

  • Vision hardware (except post-cataract surgery hardware).
  • Hearing aids, supplies and repairs.
  • Over-the-counter items.
  • Dental services that are not Medicare-covered (e.g., cleanings, X-rays, non-medical dental services).

Provider Directory Verification Is Required
Samaritan Health Plans has partnered with Quest Analytics to streamline the Provider Directory verification process through its BetterDoctor solution. Each quarter, providers will receive an email from BetterDoctor with an access token and directions about how to verify and attest to their information. 

Providers are required to review their information and make needed changes to the data. If there are no changes to be made, the provider is still required to attest that the current information is accurate. Providers who do not attest each quarter that they have completed the validation process are at risk of removal from the SHP Provider Directory due to non-compliance with the No Surprises Act.

For more information, visit BetterDoctor or contact Quest Analytics at support@betterdoctor.com. Providers may also phone Quest Analytics at 844-668-2543, Monday through Friday, 9 a.m. to 5 p.m. Central time.

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