Provider News & Updates – December 2021

Stay Informed of Updates & Changes

Samaritan Advantage Health Plans (SAHP) members will see several changes to their 2022 benefits. Along with lower premiums and copays, we’re excited about this year’s benefit line up with each of the plans now offering the following:

A pre-loaded MasterCard that can be used to pay for over-the-counter items plus dental services, routine eyewear (including glasses, frames and contacts), hearing aids (including hearing aid supplies and repairs), and preventive and comprehensive dental services.
Members will receive a credit card automatically funded with the amount covered by their chosen plan. Providers should not submit claims for services paid for with the benefit card.
Rides to and from health-related locations. We now offer a free ride with the Cascade West Ride Line to a health care provider’s office, hospital, pharmacy, fitness center, vaccination clinic or other health-related location 365 days a year, 24 hours a day.
To utilize the benefit, members contact Ride Line in advance to ensure transportation availability.

For more information about 2022 Samaritan Advantage member benefits, please visit samhealthplans.org/AdvantageBenefits.

You can also view 2022 benefits for Samaritan Choice Plans, InterCommunity Health Network Coordinated Care Organization (IHN-CCO) and our Employer Small Group Plans and Employer Large Group Plans. Please note, 2022 benefits for IHN-CCO and Employer Group Plans will not be available on our websites until Jan. 1, 2022.

Clinical Practice Guidelines Updated for Heart Disease, Congestive Heart Failure & Behavioral Health

Samaritan Health Plans develops and adopts evidence-based Clinical Practice Guidelines . The CPGs are meant to assist providers in making decisions about appropriate health care for specific clinical circumstances. They are also intended to improve the quality and consistency of care provided to members. Each SHP CPG is endorsed by a physician champion and approved by our Quality Management Council.

The Quality Management Council recently approved/endorsed:

The updated CPGs for the diagnosis and management of heart disease and congestive heart failure (CHF).
The continued use of the American Psychiatric Association (APA) guidelines and the American Society of Addiction Medicine (ASAM) guidelines and consensus documents for behavioral health.
The Oregon Health Authority (OHA) Public Health Recommendation for Community Behavioral Health Services tool to help with decision-making regarding the use of in-person versus telehealth clinical services. It provides guidance on mitigating the risk of infection as well. The OHA recommends telehealth for most community behavioral health delivery during the COVID-19 pandemic.

To review all CPGs, please visit Care Management. There you can access Clinical Guidelines to find a variety of medical guidelines as well as behavioral health and dental health guidelines.

InterCommunity Health Network Coordinated Care Organization Follows Medicaid Prescribing Regulations

In compliance with federal Medicaid program integrity regulations — 42 CFR §455.410(b), 42 CFR §455.440 and the Medicaid Provider Enrollment Compendium, Section 1.3, IHN-CCO will stop covering prescriptions written by non-Medicaid enrolled providers effective Jan. 31, 2022. This rule also applies to all pharmacists and resident providers. Keep in mind that Medicaid enrollment must be in the member’s state. Enrollment as a Medicaid provider in another state is not acceptable.

If you decide not to enroll, it is your responsibility to:

Inform any IHN-CCO patient that you are not an Oregon Medicaid provider before providing services.
If the member still wants to receive services from you, complete a form holding the patient responsible for paying for all services, including prescription drugs. This form is called the Client Agreement to Pay for Health Services form (3165) and can be found on the Tools for Oregon Health Plan providers website.

After Jan. 31, 2022, IHN-CCO will consider exceptions to rejected prescriptions on a case-by-case basis. For more information on enrolling as an Oregon Medicaid provider, visit Oregon Health Plan provider enrollment.

Durable Medical Equipment, Radiology & Lab Billing Requirements

The name of referring and ordering providers for durable medical equipment, radiology and lab services has been required on claims for IHN-CCO and Samaritan Advantage Health Plans since Dec. 1, 2021.

Beginning Jan. 1, 2022, this requirement will be extended to Samaritan Choice Plans and Employer Group Plans. For all lines of business, the provider is required to have a valid license and for IHN-CCO, providers must have a valid Oregon Medicaid ID. For additional information, please contact Samaritan Health Plans’ Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m.

Check Out These Important Reminders & Notices

Submitting Claims for Telehealth Services

Don’t forget, when submitting telehealth claims for IHN-CCO, Samaritan Choice Plans and Employer Group Plans, place of service 02 should be used and modifiers are not required. For Samaritan Advantage Health Plans telehealth claims, use modifier 95 and the same place of service as if the services had been rendered in person. For more information on billing for telehealth services, please see Telehealth Services Update.

COVID-19 Vaccination Update

Beginning Jan. 1, 2022, COVID-19 vaccinations, administration and boosters for Samaritan Advantage Health Plans’ members should be billed directly to Samaritan Advantage Health Plans rather than Medicare. For payer IDs and mailing address, review our Claims Submission Options.

Provide Original Claim Number on Corrected Claims

When submitting corrected claims, remember to reference the original claim number. The original claim number can be found on the electronic remittance advice (ERA) or through the provider portal, Provider Connect. By referencing the original claim number, you can avoid delays in processing.

Use Correct Coding for Stroke & Cerebrovascular Accident (CVA) Billing

When billing for strokes and cerebrovascular accidents for Samaritan Advantage Health Plans’ members, please remember to use acute, historical or sequelae codes, as appropriate. Your ICD-10-CM book can provide additional directions on correct coding.

Document the acute condition as appropriate.
- Refer to your ICD-10-CM book for appropriate acute condition.
Document the condition as historical if the stroke is not actively happening in the office.
- Z86.75 personal history of transient ischemic attack (TIA) and cerebral infarction without residual effects.
- Use when there are not residual effects being addressed.
Document any late effects of the stroke.
- I69.- Sequelae of cerebrovascular disease (Ex: speech and language deficits, monoplegia, hemiplegia, etc.).

Urine Drug Testing Prior Authorizations Are No Longer Required

In order to align with government and industry standards, Samaritan Health Plans has removed the prior authorization requirements for presumptive and definitive urine drug testing (UDT). It is important to remember that the benefit limits for UDT services are cumulative, therefore providers should be frequently checking available benefits.

To check available benefits, you can use the provider portal, Provider Connect, or you can contact Samaritan Health Plans’ Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m.

Line of Business	Authorization Required	Presumptive Testing	Definitive Testing	Notes
Samaritan Choice Plans	No	N/A	N/A
Employer Group Plans	No	N/A	N/A
Samaritan Advantage Health Plans	No	152 per benefit year	52 per benefit year	After exhausted, no benefits available
InterCommunity Health Network CCO	No	76 per benefit year	24 per benefit year	After exhausted, prior authorization is required.

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