Resources and Tools

Resources and Tools

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These forms apply to all plans
Prior authorization: Request prior authorization for services. See Medical Management for current prior authorization lists for all plans.
DME Prior Authorization: Request prior authorization for DME. See Medical Management for current prior authorization lists for all plans.
Imaging authorization: Request prior authorization for imaging services.
Rx exception/prior authorization: Request exception to prescription drug coverage rules.
Appeal request: Use this form to appeal a benefit coverage decision.

See below for forms that are specific to a plan.

InterCommunity Health Network Coordinated Care Organization (CCO)
Member to change PCP (SHPO-PC100_2012)
Authorization request for member vision exam and hardware (SHPO-VisionAuth100)
DMAP 741 Hysterectomy Consent
DMAP 741 Hysterectomy Consent: Spanish
DMAP 742A Consent to Sterilization-Adult 
DMAP 742A Consent to Sterilization-Spanish Adult  
DMAP 742B-Consent to Sterilization-Minor  
DMAP 742B Consent to Sterilization-Spanish Minor

Samaritan Choice Plans
Disabled Dependent Determination: Fax or mail to Samaritan Choice Plans’ for the Medical Director to review and determine patient disability.
Fax Rx for MAIL ORDER: Transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order.
NEW SamFit Physical Therapy Reimbursement Request: Submit this form for reimbursement requests for preauthorized training sessions and monthly memberships. 

Samaritan Advantage Health Plan HMO
Member to change PCP (SHPO-PC100_2012)
Fax Rx for MAIL ORDER: Transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
NEW Waiver of Liability Statement: Non-contract 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.

NEW SHS Annual Integrity Acknowledgement
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:

Register for He@lthWeb: get 24/7 online access to Samaritan Health Plans' eligibility and claims information 
Login to He@lthWeb: for registered users
VIEW He@lthWeb tutorial 
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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Requesting training

Training request form

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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 (Medicare)
Provider Directory 

Samaritan Choice Plans (Samaritan employee plan)
Primary Care Provider Directory
Specialties Directory 

InterCommunity Health Network CCO (IHN-CCO) (Oregon Health Plan)
Primary Care Provider Directory 
Specialties Directory


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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):

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).

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Reimbursement guidelines

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Medical record documentation standards

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L I N K S  T O   O T H E R   R E S O U R C E S :

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 Administrative Rules
Oregon Health Plan (OHP) Member Benefit Guide  
OHP Provider Tools 

Oregon Healthy Kids
Oregon Healthy Kids
Oregon Health Authority
Oregon Insurance Division
Department of Human Services

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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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