Provider Manual

Samaritan Health Plan Operations' Provider Manual

SHPO Provider Manual (892k)
Please feel free to print this manual to use as a desk reference.

The Provider Manual was developed for Samaritan Health Plan Operations' contracted providers to use as a tool in the delivery of healthcare to our members. This document should be used in conjunction with your contract with any of the following: Samaritan Health Plans, InterCommunity Health Network (IHN) or Samaritan Health Services (SHS).

Thank you for the quality services you provide to our members and for your commitment as our contracted provider!

Inside the SHPO Provider Manual, you will find ...


Section 1: INTRODUCTION
1.1 About this Manual
1.2 SHPO Mission Statement
1.3 History
1.4 Organizational Structure

Section 2: WHO TO CONTACT
2.1 Provider Network Management

Section 3: GLOSSARY OF TERMS

Section 4: PHYSICIANS & PROVIDERS
4.1 Eligible Providers
4.2 Credentialing
4.3 Participating Provider ID Numbers
4.3.1 Taxpayer Identification Numbers 
4.4 Provider Contract Provisions
4.4.1 Access to Care Standards
4.4.2 HIPAA
4.4.3 Regulatory Access to Books and Records
4.4.4 Termination of Member/Provider Relationship
4.4.5 Applicability of Federal Laws
4.5 On-Call Policy
4.5.1 Availability
4.5.2 On-call Availability
4.6 Primary Care Practitioners (PCP) 
4.6.1 Responsibilities
4.6.2 PCP Changes
4.6.3 Outstanding Authorizations
4.6.4 Limiting or Closing Practice
4.7 Appeals Process
4.7.1 Samaritan Choice Plans (SCP)
4.7.2 COHO benefits of CTSI
4.7.3 InterCommunity Health Network (IHN)
4.7.4 Samaritan Advantage Health Plan (SAHP)

Section 5: MEDICAL MANAGEMENT 
5.1 Program Overview
5.2 Utilization Management
5.2.1 Authorization requirements
5.2.2 Services requiring and authorization
5.3 Authorization
5.3.1 Hospital Notification
5.3.2 Out of Panel Authorization
5.3.3 Outstanding Authorizations
5.3.4 Authorizations not approved
5.3.5 Emergent/Urgent Care
5.3.6 Care Transition
5.4 Case Management
5.4.1 Health Risk Assessment
5.4.2 Identification and Referral
5.4.3 Care Planning

Section 6: QUALITY MANAGEMENT
6.1 Quality Plan
6.1.1 QM plan
6.1.2 Quality Management Committee
6.1.3 Quality Improvement Projects and Performance Improvement Projects
6.1.4 Chronic Care Improvement Program
6.1.5 Evidence-based Clinical Practice Guidelines
6.1.6 HEDIS
6.1.7 Health Outcomes Survey (H.O.S.)
6.1.8 CAHPS

Section 7: PHARMACY
7.1 Formulary & Preferred Drug List (PDL)
7.2 Drug Preauthorization
7.3 Drug Limitations
7.4 Step Therapy Protocols
7.5 Specialty Drugs

Section 8: PRODUCTS
8.1 Product Descriptions
8.1.1 Samaritan Choice Plans
8.1.2 COHO Benefits of CTSI
8.1.3 InterCommunity Health Network
8.1.4 Samaritan Advantage Health Plan

Section 9: MEMBERS
9.1 Enrollment
9.2 Member Identification
9.3 ID Cards
9.4 Members Rights and Responsibilities
9.4.1 Samaritan Choice Plans
9.4.2 COHO Benefits of CTSI
9.4.3 InterCommunity Health Network
9.4.4 Samaritan Advantage Health Plan

Section 10: FILING CLAIMS
10.1 Eligibility and Benefits
10.2 CMS-1500 Health Insurance Claim Form Instructions
10.3 UB04 Instructions
10.3.1 Claims addresses
10.4 HCPCS Coding
10.4.1 Durable Medical Equipment/Prosthetics and Orthotics
10.4.2 Drug Administration
10.4.3 Modifiers
10.5 Electronic Medical Claims
10.6 Provider Remittance Advice (PRA)/ Explanation of Benefits (EOB)
10.7 Prompt Pay Policy
10.8 Accident Report Policy
10.8.1 On-the-Job Injury
10.8.2 Motor Vehicle Accident
10.8.3 Third Party Liability
10.9 Coordination of Benefits (COB)
10.10 Overpayments
10.10.1 Collections of Charges from Members

Section 11: BILLING REQUIREMENTS
11.1 Global Period
11.2 Obstetric and Gynecology Care Billing Guidelines
11.2.1 Global OB Care
11.2.2 Partial Services
11.2.3 Screening Papanicolaou Smear – HCPCS code Q0091
11.3 Emergency Services
11.3.1 Guidelines for using CPT 99058 – Emergency Visits
11.4 Surgery
11.4.1 Bilateral Procedures
11.4.2 Multiple Procedures
11.4.3 Surgical Assistant Guidelines
11.5 Modifiers
11.6 Place of Service Codes for Professional Claims
11.7 Alcohol and/or Drug Group Therapy Sessions
11.8 Category III Codes

Section 12: PUBLICATIONS
12.1 Provider Directories
12.2 Newsletters
12.3 Web site

Section 13: COVERED EXPENSES, GENERAL EXCLUSIONS, AND LIMITATIONS
13.1 Samaritan Choice Plans (SCP)
13.2 COHO
13.3 InterCommunity Health Network (IHN)
13.4 Samaritan Advantage Health Plan (SAHP)