Provider News & Updates – September 2022

Samaritan Health Plans 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 adopted by our Quality Management Council.

The QMC recently adopted: 

  • The updated Recommended Adult and Child Preventive Screening Guideline.
  • The updated Recommended Adult Immunization Guideline.
  • The updated Recommended Childhood Immunization Guideline.

QMC also reviewed the following CPGs endorsed by the Dental Health Advisory Committee:

  • Antibiotic Use for Urgent Management of Dental Pain. 
  • Antibiotics to Prevent Infection in Prosthetic Joints. 
  • Fluoride TP for Young Children. 
  • Nonfluoride Caries Preventive Agents. 
  • Prevention of Viridans Group Streptococcal Infective Endocarditis. 
  • Topical Fluoride for Caries Prevention.
  • Diabetes.
  • Oral Health Care in Pregnancy.

To review all CPGs, please visit the Care Management webpage and click the down arrow to view the Clinical Guidelines section. There you’ll find medical, behavioral health and dental health guidelines.


Updated Medical Coverage Policies

Samaritan Health Plans develops medical coverage policies to communicate decisions about coverage and benefits for various medical services in the absence of primary clinical criteria. Medical coverage policies are reviewed annually. In 2022, SHP reviewed, updated or developed the following medical coverage policies: 

  • Coverage of Routine Care for Members Enrolled in Qualifying Clinical Trials.
  • Cosmetic and Reconstructive Procedures.
  • Advanced Care Planning.
  • Psychiatric Sub-Acute Admission. 
  • Gender Dysphoria Medical Necessity Criteria.
  • Genetic Testing. 
  • Proprietary Laboratory Analyses.
  • Applied Behavioral Analysis.
  • Drug Testing in the Outpatient Setting.
  • Botulinum Toxin (Botox).

To review all of the MCP’s, please visit the Care Management webpage and click the down arrow to view the Medical Coverage Policies section. 

Check These Important Reminders & Notices

DMAP Fee Schedule Has Been Updated

The DMAP fee schedule has been updated by the Oregon Health Authority. Please note that rates may have changed. For more information, refer to the Oregon Health Authority’s OHP Fee-for-Service Fee Schedule.

Notice About Claims Submissions

When submitting claims for patients who have Medicare or Samaritan Advantage as primary and InterCommunity Health Network Coordinated Care Organization as secondary, you do not need to submit the claim(s) to IHN-CCO as secondary. Claims are automatically crossed over to IHN-CCO for processing.

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