Medical Procedure, Specialty Drugs & Pharmacy Authorizations

Medical Procedure Authorizations

The Utilization Management team manages authorization requests made on behalf of our members. This includes medical, surgical, mental health and addiction medicine requests for inpatient, rehabilitation, DME and other specialty services requiring an authorization for the plan. 

Samaritan Health Plans will not review any retroactive requests for medical necessity unless the request meets certain exceptions outlined in our Prior Authorization FAQ.

IHN-CCO Utilization Management & Service Authorization Handbook

Utilization management (UM) is integrated within the Medical Management care management program. This handbook is designed to assist in understanding the prior authorization review process: types of reviews performed, specific criteria applied, notification process, etc. Please access this handbook for more information and step-by-step instructions for submitting online prior authorization requests. Utilization Management & Service Authorization Handbook.

The Utilization Management Program  

The Utilization Management Program is designed to assure appropriate provision of services and benefits and to increase cost efficiency while improving health outcomes for members.

The primary goal of Utilization Management is to optimize member function by providing quality services in the most efficient and effective manner to members. The program provides a systematic process to promote timely access of medically appropriate care across a network of providers, treatment facilities and services through medical management, pre-service review, concurrent review and post-service review. Read about the Utilization Management Program.

Request a Medical Procedure Authorization Electronically

Visit your provider portal to submit and track your authorizations online.

Outpatient Provider-Administered Specialty & Oncology Drug Authorizations

Samaritan Health Plans and Specialty Fusion manages authorization requests for all outpatient provider-administered specialty and oncology drugs made on behalf of members. Inpatient hospitalization and related services are exempt from review by Specialty Fusion. Please review prior authorization and drug code lists to determine if a request is necessary. 

Request a Specialty or Oncology Drug Prior Authorization

Visit the Specialty Fusion platform to submit an authorization for an outpatient provider-administered specialty or oncology drug.

Network providers may access the Specialty Fusion platform through the Provider Connect portal.

For instructions on how to navigate the Specialty Fusion prior authorization portal, please read the Specialty Fusion user guide. 

Pharmacy Authorizations

Samaritan Health Plans Pharmacy Services and OptumRX manages prescription authorization requests submitted on behalf of members. Prescription drugs provided by a pharmacy may require authorization for coverage. Please review drug lists and criteria to determine if a request is necessary. Providers who supply prescription drugs in their office should buy and bill through the medical benefit. 

Provider Prescription Prior Authorization Requests

Select medications may require prior authorization. A physician may submit authorization requests by:

  • Faxing the plan using the form below.
  • Submit electronically using one of our partners below (CoverMyMeds or Surescripts).

You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.

Understand Appeal Guidelines

Specific circumstances allow a provider to appeal for a medical, pharmacy, or durable medical equipment (DME) authorization or payment denial on behalf of a patient.

Prior Authorization Lists & Forms

Services or items requiring an authorization are identified in the plan documents and listed here by plan. Lists & Forms – Samaritan Advantage

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