Home Provider News & Updates – September 2021

Provider News & Updates – September 2021

Updates for Immunizations, Preventive Services & Diabetes

Samaritan Health Plans (SHP) develops and adopts evidence-based clinical practice guidelines (CPGs). The CPGs 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 approved by our Quality Management Council (QMC).

The QMC recently approved several updated CPGs for recommended immunizations and preventive services for adults and children, as well as recommendations for diagnosing and treating diabetes. To review all CPGs, please visit Care Management. There you can access Clinical Guidelines to find a variety of medical guidelines as well as behavioral health and dental health guidelines.

Appeals & Claim Disputes: Let’s Examine the Difference

At Samaritan Health Plans we realize there may be circumstances when a claim didn’t pay as expected or a pre-authorization was denied. Knowing whether you should file an appeal or a claim dispute can save you time and resources.

Filing an Appeal:

  • A representative from the Appeals Department will investigate your appeal.
  • Appeals can be for pre-service (authorizations) or post-service (benefits).
  • The appeals process includes strict rules and regulations set forth by Medicaid, Medicare and the federal government.
  • Member (written) consent is required for most types of appeals.
  • Forms to submit an appeal can be found at samhealthplans.org/Appeals.
  • Providers can appeal on the member’s behalf when it involves a benefit or limitation issue.
    • Examples include:
      • A pre-authorization was denied because it was determined to be medically not covered. 
      • A claim was denied due to a non-covered benefit.
      • A claim was denied because the member’s benefits have been exhausted. 
      • A claim was denied due to pre-authorization requirements.

Filing a Claim Dispute:

  • The Claims Department will investigate the claim dispute.
  • Claim disputes can be for post-service (reimbursement).
  • Member consent is not required for claim disputes. Claim disputes can be filed by contacting Samaritan Health Plan’s Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m.
  • Claim disputes are utilized when a claim did not reimburse according to the provider’s contract.
    • Examples include:
      • A code was not reimbursed at your contracted rate.
      • Claim denied due to coding errors or bundling edits.
      • Authorization issues such as the authorization was not attached to the claim or the authorization on file is not for the specific procedure.

Whether you need to file an appeal or a claim dispute, assistance can be received by contacting Samaritan Health Plan’s Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m. Samaritan strives to resolve appeals and disputes as quickly as possible, knowing the difference between the two can prevent delays in obtaining resolution. If you would like more information regarding appeals and claim disputes, please visit samhealthplans.org/Appeals and review the plan’s requirements.

Tools & Resources Simplify Processes

Samaritan Health Plans (SHP) wants our providers to have access to the tools and resources needed to support the day-to-day operations of their office. We understand our providers work with several payers which can cause confusion regarding how each payor operates. To assist you, we offer our dedicated provider website that hosts a wealth of information on our operations and how to best navigate through simple and complex processes. The website is frequently updated and does not require a login or passcode to access. All health plan related updates will be included on the website so it should be checked on a regular basis. As you navigate through the website you will discover information about:

  • SHP billing: It includes submission options, reimbursement guidelines and links to Provider Connect and tutorials. 
  • The Provider Manual: It provides additional information regarding your contractual obligations. Bookmark our website so you have plan information and updates at your fingertips. We continue to include new features and resources and welcome your feedback. Please contact Provider Relations at [email protected] or call 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 6 p.m.

Check Out These Important Reminders & Notices

Educational Opportunity

Samaritan Health Services, Evergreen Behavioral Health Association and Oregon Pacific AHEC presents:

  • More than Medicine: Creating Safety Nets for Gender Diverse Youth on Friday, Oct. 29, 2021, 8 a.m. to 12:30 p.m.

New Credentialing Application Form Is Available

Did you know there is a new version of the Oregon Practitioner Credentialing Application (OPCA)? Although the state has not mandated its use at this time, we want you to know the 2019 version is available on the Oregon Health Authority website and should be used. Some changes to the form include a section on the entity NPI and additional questions regarding admitting privileges. By utilizing the new 2019 form, providers may be added to our claims system more quickly. To view the Interactive and fillable 2019 OPCA or to get more information, please visit Oregon Health Authority: State Application: Advisory Committee on Physician Credentialing Information: State of Oregon.

No Prior Authorization Needed for Drug Testing in 2021

For the remainder of the 2021 plan year, Samaritan Advantage Health Plans will no longer require a prior authorization for drug testing. In addition, we will not be imposing any limits on coverage for the remainder of the year. If you have additional questions regarding drug testing, contact Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m.

Care Coordination Is Here to Help

If you need assistance with care coordination for InterCommunity Health Network Coordinated Care Organization (IHN-CCO) members, intensive care coordination services are available. To obtain services, providers should complete the Case Management Member Referral Form and submit it to the Case Management team. Fax to 541-768-9768 or send a secure email to [email protected]. For more information regarding intensive care coordination, please review the Provider Manual.

Provider & Demographic Changes Require Prompt Notification

All provider and demographic changes must be reported to Samaritan Health Plans within 30 days. Update your information electronically at samhealthplans.org/Update to help us provide the most accurate information to our members.

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