Resources and Tools

Authorization forms

All plans:
Rx exception/prior authorization form
Appeal request form

InterCommunity Health Network Coordinated Care Organization (CCO), Samaritan Advantage HMO, Samaritan Choice Plans:
Prior authorization form
DME prior authorization form
Imaging prior authorization form

Samaritan Employer Group Plans:
Prior authorization form
DME prior authorization form
Imaging authorization

InterCommunity Health Network CCO:
Authorization request for member vision exam and hardware form 

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Authorization lists

InterCommunity Health Network CCO Authorization List
Samaritan Advantage HMO Authorization List
Samaritan Choice Plans Authorization List 

Samaritan Employer Group Plans:
Standard, New Performance PPO and Health & Wellbeing Authorization List
Everyday Choices Authorization List
Momentum Authorization List

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Other forms

InterCommunity Health Network CCO:
Member request to change PCP form

Samaritan Choice Plans: 
Disabled Dependent Determination form 
Prescription mail order form to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
SamFit/SAM Physical Therapy Reimbursement Request form

Samaritan Advantage Health Plan HMO:
Prescription mail order form to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Member request to change PCP form
Waiver of Liability Statement – Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless in order to request a reconsideration of the plan’s denial of payment. The reconsideration must be filed within 60 calendar days from the remittance notification.

Samaritan Health Services:
SHS Annual Integrity Acknowledgement – Annual acknowledgement that provider has reviewed required Samaritan Health Services policies and procedures and agreed to act in full compliance with the principles and policies stated therein.

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Looking up member eligibility or claims status

Get 24/7 online access to Samaritan Health Plans' eligibility and claims information through your provider portal, Provider Connect:
Register for ProviderConnect
Login to ProviderConnect
View Provider Connect tutorial

Other resources:
InterCommunity Health Network CCO (IHN-CCO)-State DMAP MMIS web portal

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Reviewing member benefits

Samaritan Advantage Health Plan HMO; for enrollment information, visit our Medicare section
Samaritan Choice Plans
InterCommunity Health Network CCO (IHN-CCO)

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Appealing a service or payment denial

Guidelines for appealing a service or payment denial on behalf of a patient

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Provider referral directories

Samaritan Health Plans offer Provider Directories that make referring and collaboration of care much easier for you and your staff.  Below, Provider Directories are listed by plan for your convenience.

Samaritan Advantage Health Plan HMO:
Provider Directory  (PDF), updated weekly

Samaritan Choice Plans:
Primary Care Provider Directory (PDF), updated weekly
Specialty Directory (PDF), updated weekly

InterCommunity Health Network CCO:
Primary Care Provider Directory (PDF), updated weekly
Specialty Directory (PDF), updated weekly
Dental Plan Directory (PDF), updated weekly

Samaritan Employer Group Plans
List of Primary Care Providers (PDF), updated weekly
List of Specialty Providers (PDF), updated weekly

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Guidelines for preventive care services and immunizations

These guidelines are comprised of recommendations from the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control (CDC):
Preventive Care Services Guidelines
Immunizations Guidelines

Below is a side-by-side comparison of the Welcome to Medicare Visit, Annual Wellness Visits, and Preventive Medicine Services codes. Samaritan Advantage Health Plan covers all of these codes (G0402, G0438, G0439, and 99381-99429). When billing SAHP with these codes, there is a $0.00 cost share to the Samaritan Advantage  member. It is at the discretion of the provider to provide and code the appropriate level of a preventive comprehensive physical exam for the Medicare patient. Samaritan Health Plans encourages providers to conduct a full annual comprehensive exam (99381-99429).
Annual Preventive Exams for Medicare Patients

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Reimbursement guidelines

Screening, Brief Intervention and Referral to Treatment (SBIRT) Services
Developmental Screenings

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Medical record documentation standards

Introduction to medical record documentation
Guidelines for medical record documentation standards

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Links to other resources 


CMS home   
Social Security Administration 
Senior Health Insurance Benefits Assistance Program (SHIBA) 

Oregon Health Plan (Medicaid)
Division of of Medical Assistance Programs (DMAP) Fee Schedule
DMAP Prescription Drug Plan
Oregon Health Plan (OHP) Member Benefit Guide  
OHP Provider Tools 


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Common acronyms translated

DMAP - Division of Medical Assistance Programs
IHN-CCO - InterCommunity Health Network Coordinated Care Organization
OHA - Oregon Health Authority
OHP - Oregon Health Plan
SAHP - Samaritan Advantage Health Plan HMO
SCP - Samaritan Choice Plans

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