Provider News & Updates – March 2023

Effective Jan. 1, 2023, services provided to Samaritan Health Plans and InterCommunity Health Network Coordinated Care Organization members during the provider credentialing review period are eligible for reimbursement once credentialing has been approved. SHP’s new policy allows for providers to treat SHP/IHN-CCO members during the credentialing period to increase access to care and reduce wait times for members to be seen.

Eligibility for claims reimbursement begins either the date a completed credentialing application is received by the SHP Credentialing Department or the effective date of the provider’s contract with SHP/IHN-CCO, whichever is later. However, claims for dates of service during the credentialing period should be submitted only after the provider’s credentialing is fully approved. Claims submitted with receipt dates prior to the provider being fully credentialed will continue to be denied. To avoid claims resubmission and reprocessing, please pause billing until credentialing is approved.

If a provider’s credentialing application is denied or there is no contract in effect between the provider and SHP/IHN-CCO on the date of service, the services will be considered out-of-network and will be processed according to plan benefits and out-of-network authorization requirements.

Samaritan Health Plans will soon launch a Rewards and Incentives Program. This program is available to all Samaritan Advantage Plans members who receive their recommended annual preventive screenings. The program launch is planned for April 1 and rewards will be granted to members for all 2023 visits through December 31. Upon SHP’s receipt of a claim for an initial qualifying service, the member will be mailed a reusable debit card loaded with their earned monetary rewards. Additional qualifying services will have applicable rewards automatically added to the member’s card. Members can use the rewards card to make purchases at various community retailers including grocers, pharmacies, home improvement supply stores and many others. This program is offered as a continuation of our partnership with Employee Benefits Corporation (EBC) which administers the Samaritan Advantage member Benefits MasterCard.

Members will receive rewards in the amounts shown for the following preventive services:

• Health risk assessment completion:
  • $25 reward (1 per calendar year).
• Annual Wellness Visit/Annual Physical Exam/Welcome to Medicare Visit:
  • $25 reward (1 per calendar year).
  • CPT/HCPC codes: 99381-99397, 99429, G0402, G0438, G0439, G0468.
• Bone density measurement test:
  • $20 reward (1 per calendar year).
  • CPT/HCPC codes: 76977, 77078, 77080, 77081, 77085, 77086, G0130.
• Breast cancer screening:
  • $20 reward (1 per calendar year).
  • CPT/HCPC codes: 77063, 77067, G0202.
• Cervical cancer screening:
  • $20 reward (1 per calendar year).
  • CPT/HCPC codes: G0476, G0101, G0123, G0124, G0141-G0148, 87623-87625, 88141-88143, 88147-88155, 88164-88167, 88174, 88175.
• Colorectal cancer screening:
  • $20 reward (1 per calendar year).
  • CPT/HCPC codes: G0104, G0105, G0106, G0120, G0121, G0122, G0327, G0328, G6025, S0601, 00811, 00812, 44388-44394, 44401-44408, 44799, 45330-45346, 45378-45385, 45388-45389, 45399, 81528, 82270-82274, 88304, 88305.
• Diabetes screening:
  • $10 reward (2 per calendar year).
  • CPT/HCPC codes: 82947, 82950, 82951, 82952, 83036.
• Flu vaccination:
  • $25 reward (1 per calendar year).
  • CPT/HCPC codes: 90662, 90672, 90674, 90682, 90685, 90686, 90687, 90688, 90694, 90756, Q2039.
• Glaucoma screening:
  • $10 reward (1 per calendar year).
  • CPT/HCPC codes: G0117, G0118.
• Prostate cancer screening:
  • $20 reward (1 per calendar year).
  • CPT/HCPC codes: G0102, G0103.

Additional information will be provided prior to the April 1 launch date. Questions or concerns about the program can be directed to the Medicare Programs team at SHPMedicarePrograms@samhealth.org.

Electronic Tertiary Billing Now Accepted

Effective Jan. 13, 2023, claims for coordination of benefits in the tertiary position are now accepted electronically. For prompt reimbursement, please include all relevant EOB data from both the primary and secondary payers.

Claims for Evaluation & Management Codes with Vaccinations
Practitioner evaluation and management office visits that include the administration of one or more vaccinations should be billed on a single claim when performed together on the same date of service. Services split into two or more claims will process with a “clinical edit” and disallow full reimbursement. Please bill modifiers, as appropriate, based on established coding guidelines. By billing these services together, both the provider and Samaritan Health Plans can avoid the additional administrative costs and reprocessing time associated with corrected claim submissions.

Quarterly Provider Webinar to Be Held in Early March

Attend one of the Samaritan Health Plans quarterly provider webinars to receive provider-related updates and information from SHP and IHN-CCO. If you would like to attend but did not receive an invitation, please email shpprovider@samhealth.org for an invite to the current session. To ensure receipt of future webinar invitations, please sign up for Provider News at News for Clinic Managers & Staff.

When: March 8, 1 to 2 p.m., or March 9, 10 to 11 a.m.

Where: Virtual Teams Meeting

New Contact Information for Pharmacy Prior Authorizations

Samaritan Health Plans has implemented new fax numbers for pharmacy authorization requests. All requests for pharmacy prior authorizations should be submitted to the new fax numbers below, specific to each separate line of business.

Providers utilizing the electronic prior authorization submission site, CoverMyMeds, for Samaritan Advantage Plans or Employer Group Plans, may see the OptumRX logo in the form name. This is expected and the form will be received by the SHP delegate, OptumRX, for review.

Sterilization Consent Forms Required for InterCommunity Health Network Members
Oregon law requires informed consent to be obtained from any IHN-CCO member who requests voluntary sterilization or a hysterectomy. Without proper consent, it is prohibited to use state or federal dollars to perform these services. The Oregon Health Authority has specific online forms that must be completed at least 30 days, but no more than 180 days, prior to the procedure. IHN-CCO is required to submit consent forms to OHA for any sterilization or hysterectomy claims received. If the consent form is incomplete and/or not included with the claim submission, claims for sterilization will be denied. To assist you with completing this, please follow these tips:

• All fields must be complete and legible.
• Member signatures on the consent form should be collected at least 30 days, but no more than 180 days, prior to the procedure. Electronic signatures are not allowed.
• Any interpreter’s statement must be signed and dated the same day as the member’s signature.
• The statement of the person collecting the consent must be signed and dated the same day as the member’s signature.
• The physician’s signature must be dated on the date of the procedure.
• The consent form must be included with the claim submission for reimbursement.

Sterilization forms can be found on OHA’s website in English and Spanish. 

EBC Benefits MasterCard Covers Supplemental Benefits Only

The Employee Benefits Corporation (EBC) Benefits MasterCard provided to Samaritan Advantage members is for coverage of supplemental benefits only. Providers should not be asking for or processing a member’s EBC card to cover copays or to make payments on services that are covered by Medicare.

Supplemental benefits eligible for payment using the EBC card include:

• Vision hardware (except post-cataract surgery hardware).
• Hearing aids, supplies and repairs.
• Over-the-counter items.
• Dental services that are not Medicare-covered (e.g., cleanings, X-rays, non-medical dental services).

Provider Directory Verification Is Required
Samaritan Health Plans has partnered with Quest Analytics to streamline the Provider Directory verification process through its BetterDoctor solution. Each quarter, providers will receive an email from BetterDoctor with an access token and directions about how to verify and attest to their information. 

Providers are required to review their information and make needed changes to the data. If there are no changes to be made, the provider is still required to attest that the current information is accurate. Providers who do not attest each quarter that they have completed the validation process are at risk of removal from the SHP Provider Directory due to non-compliance with the No Surprises Act.

For more information, visit BetterDoctor or contact Quest Analytics at support@betterdoctor.com. Providers may also phone Quest Analytics at 844-668-2543, Monday through Friday, 9 a.m. to 5 p.m. Central time.