Medical Management

Medical Management Program Overview

The Medical Management department oversees the clinical operations at Samaritan Health Plans. The program goals and objectives are to insure that the members receive high quality medical and mental health care within a defined plan benefit and through a delivery system that encourages an integrated approach to the utilization of services. See the Provider Manual for more detail on the Medical Management Programs and the authorization process for medical, surgical, mental health and addiction services.

Utilization Management

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.

Services or items requiring an authorization are identified in the plan documents and can be viewed through the List of Services link below. Authorizations are processed as standard (14 business days) or expedited (72 hours from receipt of request).


Authorization Lists-located on each plan's Member page

Authorization Forms

Case Management Services

Support and assist members who are experiencing immediate and on-going medical conditions or injuries that may require complex, high-intensity, long-term and /or high utilization of services. The team is composed of case management nurses; an exceptional needs care coordinator, a behavioral health coordinator and office support. 
 
Case management services target diagnosis-specific conditions, individuals at-risk, are special needs or members that meet the criteria for health plan quality improvement projects or collaborative initiatives.  Referrals can be submitted through member self referral, health care staff,  physicians, caregiver or  family member,  facility and / or agency working with the member who has the benefit.

  • Members and Providers may contact member services to make a referral.
  • No specific form is required.
  • Members in an eligible plan can agree to opt-out of the program when contacted by the case management department.