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Provider News & Updates – March 2022

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Provider News

Samaritan Advantage Health Plans Maintains High Stars Rating

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The Centers for Medicare & Medicaid Services evaluates Medicare Advantage plans annually using a one-to-five-star quality rating system, with five stars representing excellent performance. Star ratings are calculated as a composite of measures that address member perceptions of service and care, and how well they were able to talk with their doctor, stay healthy and use prescribed medications.

Samaritan Advantage maintained a four-star rating for the most recent 2022-Star rating, which is generally reflective of services provided in 2020. However, due to the COVID-19 pandemic, most Medicare Advantage plans were granted disaster adjustments allowing plans to use the better of their 2021 or 2022 Star rating for many Star measures. This combined with changes made in prior Star ratings means some of the measures in the 2022 Star rating are reflective of performance as far back as 2018. This greatly benefited plans and led to what is likely a one-time anomaly of unusually high star ratings for Medicare Advantage plans. In fact, the number of five star plans almost quadrupled in the 2022 Star ratings.

Our goal is to continue to improve performance across Samaritan Health Plans and the provider network to earn a five Star for the 2025 Star rating. To achieve this goal, we include Star measures in provider value-based payments, assist with identifying members with a care gap, and created programs to help members manage chronic conditions and stay healthy. We are enhancing our website with helpful information on Star measures and best practices to achieve high performance. We are also offering members incentives to get needed services, focusing on improving member experience and creating a formal Stars program.

If you would like to learn more or be involved with our Stars initiatives, please contact to Kevin Ewanchyna, MD at kewanchy@samhealth.org or Barbara Boardman at bboardman@samhealth.org.

Samaritan Advantage Launches a Prepaid Benefits Debit Mastercard

Samaritan Advantage Health Plans is providing our members with an easy way to pay for some qualified health care expenses, such as eligible over-the-counter items and certain dental, vision and hearing benefits. The prepaid benefits debit Mastercard® is loaded with the value of these supplemental benefits, according to the member’s specific plan.

If you bill a member’s card for services that should have been billed to the plan (e.g., hearing or eye exams) or charge the member more than you should have, you can simply process a refund to the member’s card.

If a member has secondary insurance coverage, you will need to bill the secondary insurance directly and provide a receipt that shows payment was made to their benefits card. These transactions do not generate a formal PRA or EOB.

If the member has lost or can’t find their card, a new one can be ordered by logging into our member portal at myhealthplan.samhealth.org and clicking on Benefits Card login or by contacting Customer Service at 800-832-4580 (TTY 800-735-2900). It will take approximately 10 to 14 days for the member to receive a new card.

See below for more details about the services covered by the benefits card.

Dental Services

The member’s benefits card should be used to pay for exams, cleanings, X-rays, fillings, periodontal services, restorative services, endodontic services, fluoride treatments, etc. The SAHP dental benefit does not cover orthodontia. SAHP should no longer be billed for these services.

The benefits card can be used at any dental provider’s office who accepts Mastercard, has not opted out of Medicare and who has a Merchant Category Code of 8021 (dentists, orthodontists).

The benefits card cannot be used for Medicare-covered dental services (services by a dentist or oral surgeon are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease or services that would be covered when provided by a doctor). If you provide Medicare-covered dental services to a member of SAHP, a claim should be submitted to SAHP accordingly.

Effective Jan. 1, 2022, SAHP offers the following combined annual amounts for preventive and comprehensive dental services (the Special Needs Plan does not offer additional dental coverage):

Plan Dental Benefit
Conventional Plan (001) $750 / year
Premier Plan (002) $1,000 / year
Premier Plan Plus (009) $2,000 / year

Hearing Aids, Hearing Aid Supplies & Repairs

The member’s benefits card should be used to pay for hearing aids, hearing aid supplies and hearing aid repairs. SAHP should no longer be billed for these services.

The benefits card can be used at any hearing aid provider office that accepts Mastercard, has not opted out of Medicare and that has a Merchant Category Code of 5975 (hearing aids). If you are a physician’s office or clinic providing hearing aids to a member, the card will not work because your payment system will not have the correct MCC. If the member would still prefer to purchase hearing aids from you rather than a hearing aid merchant, they will have to pay out of pocket and submit for reimbursement.

The benefits card does not cover hearing exams (unless the cost of a hearing aid fitting/evaluation is bundled into the cost of a hearing aid, which would be paid for using the benefits card). If you provide a covered hearing exam to an SAHP member, a claim should be submitted to SAHP accordingly.

Effective Jan. 1, 2022, SAHP offers the following combined annual benefit amount for hearings aids, hearing aid supplies and hearing aid repairs:

Plan Hearing Aid, Hearing Aid Supplies & Hearing Aid Repairs Benefit
Conventional Plan (001) $500 / year
Premier Plan (002) $500 / year
Premier Plan Plus (009) $1,000 / year
Special Needs Plan (003) $750 / year

Routine Vision Hardware

The member’s benefits card should be used to pay for routine eyeglasses (lenses, frames and upgrades) and contact lenses. SAHP should no longer be billed for these services. Should you submit a claim, you will receive a remittance with a denial that indicates the member should pay with their benefits card.

The benefits card can be used at any vision provider’s office that accepts Mastercard, has not opted out of Medicare and that has a Merchant Category Code of 8042 (optometrists, ophthalmologists) or 8043 (opticians, optical goods and eyeglasses).

The benefits card does not cover vision exams, glaucoma screenings, eyeglasses or contact lenses after cataract surgery. If you provide any of these services to an SAHP member, a claim should be submitted to SAHP accordingly.

Effective Jan. 1, 2022, SAHP offers the following annual amounts for routine vision hardware:

Plan Routine Vision Hardware Benefit
Conventional Plan (001) $125 / year
Premier Plan (002) $125 / year
Premier Plan Plus (009) $125 / year
Special Needs Plan (003) $175 / year

Over-The-Counter Items

Members are given a quarterly benefit allowance to purchase eligible over-the-counter items. The amount must be used each quarter and any unused dollars do not roll over to the next quarter. The card is automatically replenished at the start of each quarter (January, April, July and October).

The card can be used at most pharmacies, stores and online merchants who accept Mastercard.  For the card to work properly, the merchant must use an inventory information approval system (IIAS). Examples of common retailers in our service area are Fred Meyer, Rite Aid, Bi-Mart, Walgreens and Walmart. The store’s IIAS will compare the item being purchased to a list of eligible OTC items that is maintained by SIGIS (The Special Interest Group for IIAS Standard) and automatically approve or deny at the register.

A list of OTC items that are considered eligible is available on our website at samhealthplans.org/AdvantageBenefits. Some items that are listed as eligible may still deny at the register if the store’s IIAS is not up to date, or the item being purchased is not included on the SIGIS list. If the member pays out of pocket for an eligible item, they may submit for reimbursement.

Because the source of the SIGIS list is nationally distributed, private label and store branded products will generally not be covered, unless the store has submitted a request to have store-branded items added to the list. Those items that CMS has deemed “dual-purpose,” such as vitamins and minerals, are also not covered at the register but members may pay out of pocket and submit for reimbursement.

Effective Jan. 1, 2022, SAHP offers the following annual amounts for eligible over-the-counter items:

Plan OTC Benefit
Conventional Plan (001) $100 / quarter
Premier Plan (002) $100 / quarter
Premier Plan Plus (009) $100 / quarter
Special Needs Plan (003) $150 / quarter

If you need further information about accepting the Mastercard benefit debit card, contact Customer Service at 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 8 p.m.

Guidance on Benefits Limits on Urine Drug Testing

In addition to prior authorizations for urine drug testing information that was presented in last quarter’s provider newsletter, Samaritan Health Plans would like to provide further guidance on benefit limits for urine drug testing. We have also made a correction on testing limits for Samaritan Advantage Health Plans (SAHP) members. Please note the revised limits are 152 presumptive testing per benefit year and 52 definitive testing per benefit year.

In accordance with Current Procedural Terminology and CMS guidelines, only one drug test within the presumptive (drug screening) drug class and one within the definitive (drug confirmation) drug class will be allowed per date of service by the same or different provider. If multiple testing claims are received for the same patient on the same date of service, Samaritan Health Plans will only pay the first claim received. Validity testing used for drug testing should not be billed separately, as they are included in the presumptive and definitive drug class. In addition, testing is solely a per patient service that should only be reported once, irrespective of the number of drug class procedures or results on any date of service.

To learn more about billing urine drug testing, please review the National Correct Coding Initiative Policy Manual for Medicare Services.

Line of Business Authorization Required Presumptive Testing Definitive Testing Notes
Samaritan Choice Plans No Limit one per date of service Limit one per date of service
Employer Group Plans No Limit one per date of service Limit one per date of service
Samaritan Advantage Health Plans No

152 per benefit year

Limit one per date of service

52 per benefit year

Limit one per date of service
After exhausted, no benefits available.
InterCommunity Health Network No

76 per benefit year

Limit one per date of service

24 per benefit year

Limit one per date of service
After exhausted, prior authorization is required.

Check These Important Reminders & Notices

Access to Care: Oregon Psychiatric Access Line

Are you a primary care provider and have a patient who is needing psychiatric medication? OHSU’s Oregon Psychiatric Access Line provides free, same-day, Monday through Friday, 9 a.m. to 5 p.m., child and/or adult psychiatric phone consultations to primary care providers. Worried about hold times? Ninety-five percent of calls for adult and 80% for child psychiatric medication consults are directly connected to a psychiatrist. This program expands the availability of high-quality mental health treatment to Oregon youth and adults via timely psychiatric consultation, medical practitioner education and connections with mental health professionals throughout the state. For more information, check out OHSU’s Oregon Psychiatric Access Line | OHSU website.

Prior Authorization Updates

Don’t forget, the prior authorization lists have been updated for 2022 so make sure to review them to be aware of any changes. Retroactive requests are only reviewed in extenuating circumstances so obtaining prior authorizations are a crucial component of timely reimbursements. To review the prior authorization lists, visit the Authorization page under Care Management.  A quick way to get there is the Request Authorization link on the Provider home page.

The six colorful quick links on the provider home page, will guide you to the most utilized pages on the provider website.

Unlisted & Not Otherwise Classified Code Usage

When billing unlisted and not otherwise classified codes, it is the responsibility of the provider to ensure all required information is included on the CMS-1500, UB-04 form or the electronic media claim. Unlisted and NOC codes require a concise description of the service, procedure or supply rendered in Item 19 on the CMS-1500 claim form or electronic equivalent. To learn more about billing unlisted and NOC codes, go to Unlisted and Not Otherwise Classified Code Billing - JF Part B - Noridian (noridianmedicare.com).

Annual Wellness Visit Packets

Throughout February, Samaritan Advantage members will be receiving packets in the mail containing an annual care checklist and a Guide to Medicare Wellness Benefits brochure. Members are encouraged to bring the checklist to their next appointment with their primary care provider to ensure needed care, screenings and tests are discussed. If you have questions regarding the checklist and guide, contact Provider Relations at shpprovider@samhealth.org or call 541-768-5207 or 888-435-2396, Monday through Friday, 8 a.m. to 6 p.m.

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