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Take advantage of the support and assistance available for patients who are experiencing immediate and on-going medical conditions or injuries that may require complex, high-intensity, long-term and/or utilization of services.

Support & Assistance Available

We offer support and assistance to members who are experiencing immediate and on-going medical conditions or injuries that may require complex, high-intensity, long-term and /or high utilization of services. Our case management team is composed of case management nurses, exceptional needs care coordinators, and behavioral health coordinators.

Case management services target diagnosis-specific conditions, individuals at-risk, special needs, and members that meet the criteria for health plan quality improvement projects or collaborative initiatives.  Referrals can be submitted through member self-referral, health care staff,  physicians, caregiver or  family member,  and facility or agency working with the member who has the benefit.

How to Make a Referral

Members and providers should complete the Case Management Member Referral Form and submit it to the Case Management Team. Fax to 541-768-9768 or send secure email to carecoordinationteam@samhealth.org.

Members in an eligible plan can agree to opt-out of the program when contacted by the Case Management Department. 

Clinical Practice Guidelines

Evidence-based clinical practice guidelines are developed to assist providers and members in making decisions about appropriate health care for specific clinical circumstances including “self-management” of chronic diseases.  The guidelines are intended to improve the quality and consistency of care provided at the provider level.  A physician champion is utilized in the development of these guidelines prior to the approval of each guideline by our Quality Management Council and then they are disseminated to providers.

Adult Immunizations

Adult and Child Preventive Screenings 

Asthma

Child Immunizations

Congestive Heart Failure

Diabetes

Heart Disease

Hypertension

Obesity

Oral Health in Pregnancy

Osteoporosis

Pediatric Preventive Screenings

Tobacco Cessation

Behavioral Health Guidelines

Samaritan Health Plans’ partners in behavioral health and substance use disorder follow evidence-based clinical practice guidelines that are in alignment with the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM) guidelines:

APA’s Clinical Practice Guidelines
ASAM’s Clinical Guidelines

The Oregon Health Authority (OHA) recommends telehealth for most community behavioral health delivery during the COVID-19 pandemic. The OHA Public Health Recommendation for Community Behavioral Health Services is a tool to help with decision-making regarding the use of in-person versus telehealth clinical services and provides guidance on mitigating the risk of infection as well.  

Dental Health Guidelines

Samaritan Health Plans’ Dental Care Organization (DCO) partners follow evidence-based clinical practice guidelines that are in alignment with American Dental Associations (ADA) clinical practice guidelines list:

ADA’s Clinical Practice Guidelines

Preventive Care and Immunization Guidelines

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 (Updated September 2021)

Immunizations Guidelines (Updated January 2021)

Annual Preventive Exams for Medicare Patients

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

 

Medical Coverage Policies

Medical Coverage policies are developed to communicate Samaritan Health Plan decisions about coverage and benefits for various medical services. Each coverage policy contains a description of the medical and behavioral health service, as well as the coverage determination, product application, coding considerations and requirements for prior authorization. Determinations are made after careful consideration of evidence, product or service factors, regulatory/compliance, operational issues, community standards, service availability, and other pertinent factors.

Evidence-based Utilization Management

Samaritan Health Plans performs utilization management using nationally recognized evidence-based guidelines from MCG Health. Care guidelines from MCG provide evidence-based medicine’s best practices and care plan tools across the continuum of treatment, providing clinical decision support and documentation which enables efficient transitions between care settings. Eight of the largest U.S. health plans and nearly 1,900 hospitals use MCG Health’s evidence-based guidelines and software. MCG Health’s informed care strategies affect over 208 million covered lives.

It should be noted that the conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Samaritan Health Plans) for a particular member. The member’s benefit plan determines coverage. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.

MCG Health

For Samaritan’s Medicare Advantage Health Plans we use applicable content from Medicare National Coverage Determinations, Local Coverage Determinations, and the Medicare Benefit Policy Manual.

CMS Medicare National Coverage Determinations
CMS Medicare Local Coverage Determinations
Medicare Benefit Policy Manual

Our Intercommunity Health Network CCO plan follows coverage guidelines and funding limitations that govern the Oregon Health Plan (Oregon Medicaid) established by the Oregon Legislature and Oregon Health Authority in the Prioritized list of Health Services and Oregon Administrative Rules:

Oregon Medicaid Prioritized list (which includes above the line & below the line information as well as guideline notes developed by the state HERC)
Oregon Administrative Rules (see chapters 409-418)

On the rare occasion that no appropriate guideline exists from the sources above Samaritan Health Plans uses a small number of internally developed Samaritan Health Plan Medical Coverage Policies, listed below:

Advanced Care Planning Policy
Applied Behavioral Analysis
Computer Assisted Surgical Navigational Procedure
Drug Testing in the Outpatient Setting
Evaluation of New and Existing Technologies
Gender Dysphoria Medical Necessity Criteria Policy
Genetic Testing
Proprietary Laboratory Analyses
Psychiatric Sub-Acute Admission
Wireless Gastrointestinal MonitoringSystem

 

Standards & Guidelines

A patient’s medical record is the historical account of the patient/provider encounter and serves as a legal document for use in legal proceedings. Good healthcare decision making is dependent upon a provider’s ability to retrieve accurate and complete facts from the patient’s record. To assist you in providing proper medical record documentation, here are some helpful guidelines for your reference.

Medical Record Documentation Standards

Samaritan Health Plans submits all Medicare member diagnoses submitted on a claim for the purposes of risk adjustment payments. A patient’s medical record must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services.

When the appropriate documentation is not included, we may be unable to confirm that payment was made appropriately. This can result in a request for refunds from providers. The Centers for Medicare and Medicaid Services (CMS) will consider the diagnoses submitted as not existing and will request refunds from us.

The rule of thumb is, “If it is not documented, it does not exist.” and, therefore, is not payable. Proper and accurate medical documentation is essential to proper and accurate payment of claims. CPT codes and ICD-9-CM codes reported on the health insurance claim form or billing statements must be supported by the documentation in the patient’s medical record.

Samaritan Health Plans and InterCommunity Health Plans follow Medicare standards for proper documentation, including record retention. All medical records must be maintained for at least ten years after the date of medical services. Proper record retention is important, especially in the event of an audit.

 
In an effort to support and promote safe opioid use and appropriate pain management, Samaritan Health Plans has implemented new opioid limitations and authorization criteria. See the opioid reduction guidelines.

Quality Improvement Program Helps Members

The purpose of the Quality Improvement Program is to provide a formal process to monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and services provided to our members using an interdisciplinary and multidimensional approach.

The Quality Improvement Program’s Goals

  • Deliver quality care and services that set community standards. Maintaining processes to ensure evidence-based clinical practice guidelines are adopted, regularly reviewed, approved, and disseminated to network providers. Systematically evaluate delivery of services in accordance with approved guidelines and clinical performance indicators.
  • Give members care that is compassionate and effective. Integrating behavioral health, addressing the whole person including social determinants of health and health equity, individualizing care, engaging in health promotion and education of preventive services and active self-management.
  • Exceed members’ expectations of care. Actively monitoring member perception of network providers and their health outcomes to identify trends and opportunities for quality improvement through member experience feedback and CAHPS (Consumer Assessments of Healthcare Providers and Systems) and HOS (Health Outcomes Survey).
  • Engaged and aligned provider network. Building relationships and engaging clinicians in quality improvement work that is physician-led, evidence-based, and data driven.

The Quality Improvement Program encompasses Population Health Management and describes organizational framework, scope, and objectives for improving the safety, quality, experience, and affordability of health care for our members. The Quality Improvement Program provides an overview of the structure, responsibilities, program components, and activities in place to monitor and improve the quality of health care services and health outcomes. The Quality Improvement Program is updated annually to respond to the changing needs of members, clinical standards, and regulatory and accrediting standards. A yearly evaluation is done to look for opportunities to improve the Quality Improvement Program

Quality Projects

The Quality Improvement Program includes many quality improvement projects. Some quality improvement projects are specific to a line of business, but the goal is to improve care and services across all lines of business. Quality Project List.