Provider Manual - Healthier Together - Samaritan Health Plans
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Provider Manual Healthier Together
Table of contents
Section 1: Introduction . . . . . . . . . . . . . . . . . . . . 4 Section 4: Care coordination. . . . . . . . . . . 15
1.1 About us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4.1 Utilization management . . . . . . . . . . . . . . . 15
Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4.2 Utilization
1.2 About this manual. . . . . . . . . . . . . . . . . . . . . . . 4 management disclaimer. . . . . . . . . . . . . . . 15
1.3 Lines of business. . . . . . . . . . . . . . . . . . . . . . . . 5 4.3 Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Samaritan Advantage Health Plans. . . . . . . 5 4.4 Clinical criteria. . . . . . . . . . . . . . . . . . . . . . . . . . 17
InterCommunity Health Network
4.5 Medical coverage policies. . . . . . . . . . . . . 17
Coordinated Care Organization. . . . . . . . . . . 5
Samaritan Choice Plans. . . . . . . . . . . . . . . . . . . 6 4.6 Peer-to-peer consultation. . . . . . . . . . . . . 17
Samaritan Employer Group Plans. . . . . . . . . 6 4.7 Referrals for
out-of-network services. . . . . . . . . . . . . . . 18
Section 2: Contact us . . . . . . . . . . . . . . . . . . . . . . 7 Out-of-state services . . . . . . . . . . . . . . . . . . . . . 18
4.8 Care management services. . . . . . . . . . . 18
Section 3: Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Intensive Care Coordination (ICC) . . . . . . . 18
3.1 Eligibility and benefits . . . . . . . . . . . . . . . . . . 8 Maternity case management . . . . . . . . . . . . 19
3.2 General claims information . . . . . . . . . . . . 8 Complex case management . . . . . . . . . . . . . 19
3.3 Oregon Medicaid Registration. . . . . . . . . 8 Getting to know the Samaritan
Health Plans’ care team. . . . . . . . . . . . . . . . . . 20
3.4 Electronic claims submission. . . . . . . . . . 8
How to contact Care Coordination. . . . . . . 20
3.5 Electronic funds transfer (EFT). . . . . . . . 8
3.6 Electronic remittance advice. . . . . . . . . . . 9 Section 5:
3.7 Paper claims submission. . . . . . . . . . . . . . . 9 Quality Management Program . . . . . . . . 21
3.8 Monitoring submitted claims . . . . . . . . . 10 5.1 Quality Improvement Workplan. . . . . . . 21
3.9 Claims editing and pricing . . . . . . . . . . . . 10 5.2 Quality Management Council
(QMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.10 Prompt payment. . . . . . . . . . . . . . . . . . . . . . . . 11
5.3 Quality improvement projects . . . . . . . . 21
3.11 Coordination of benefits
and third-party liability . . . . . . . . . . . . . . . . 11 5.4 Evidence-based clinical
practice guidelines. . . . . . . . . . . . . . . . . . . . . 22
3.12 Balance billing . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Samaritan Advantage Health Plans. . . . . . 11 5.5 HEDIS/HOS/CAHPS. . . . . . . . . . . . . . . . . . . . 22
InterCommunity Health Network
Coordinated Care Organization . . . . . . . . . 12 Section 6:
3.13 Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Appeals and grievances. . . . . . . . . . . . . . . . . 23
6.1 Samaritan Advantage
3.14 Timely filing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Samaritan Advantage Health Plans. . . . . . 13
Urgent situations:
InterCommunity Health Network CCO. . . 14
Pre-service denials . . . . . . . . . . . . . . . . . . . . . . . 23
Samaritan Choice Plans. . . . . . . . . . . . . . . . . . 14
Standard pre-service denials. . . . . . . . . . . . . 23
Samaritan Employer Group Plans. . . . . . . . 14
Payment denials. . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.15 Reimbursement guidelines. . . . . . . . . . . . 14 Time frame to appeal . . . . . . . . . . . . . . . . . . . . 24
Provider Manual 1Table of contents
6.2 InterCommunity Health Network 8.2 Primary care providers . . . . . . . . . . . . . . . . 33
Coordinated Care Organization. . . . . . . 25 8.3 Locum tenens. . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Urgent situations . . . . . . . . . . . . . . . . . . . . . . . . . 25
8.4 Traditional health workers . . . . . . . . . . . . 33
Standard pre-service and
payment denials. . . . . . . . . . . . . . . . . . . . . . . . . . 25 8.5 Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Time frame to appeal . . . . . . . . . . . . . . . . . . . . 26 Samaritan provider network . . . . . . . . . . . . . 34
Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 First Choice Health Network . . . . . . . . . . . . 34
Time frame for grievances. . . . . . . . . . . . . . . 27 First Health Network . . . . . . . . . . . . . . . . . . . . . 34
Reliant Behavioral Health . . . . . . . . . . . . . . . . 34
6.3 Samaritan Choice Plans. . . . . . . . . . . . . . . 27
CHP Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Urgent situations . . . . . . . . . . . . . . . . . . . . . . . . . 27
Standard pre-service and 8.6 Contracting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
payment denials. . . . . . . . . . . . . . . . . . . . . . . . . . 27 8.7 Credentialing. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Time frame to appeal . . . . . . . . . . . . . . . . . . . . 28 Initial credentialing process. . . . . . . . . . . . . . 36
6.4 Samaritan Employer Phase 1: Application. . . . . . . . . . . . . . . . . . . . . . 36
Group Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Provider credentialing. . . . . . . . . . . . . . . . . . . . 36
Urgent situations . . . . . . . . . . . . . . . . . . . . . . . . . 28 Facility credentialing . . . . . . . . . . . . . . . . . . . . . 37
Standard pre-service and Phase 2: Review . . . . . . . . . . . . . . . . . . . . . . . . . . 37
payment denials. . . . . . . . . . . . . . . . . . . . . . . . . . 28 Phase 3: Decision . . . . . . . . . . . . . . . . . . . . . . . . 37
Time frame to appeal . . . . . . . . . . . . . . . . . . . . 28 Adequate professional liability
coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 7: Pharmacy . . . . . . . . . . . . . . . . . . . . . 29 Recredentialing. . . . . . . . . . . . . . . . . . . . . . . . . . . 38
7.1 Formulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Practitioner rights . . . . . . . . . . . . . . . . . . . . . . . . 38
7.2 Non-formulary drugs. . . . . . . . . . . . . . . . . . . 30 8.8 Update your information. . . . . . . . . . . . . . . 39
Demographic information. . . . . . . . . . . . . . . . 39
7.3 Specialty drugs . . . . . . . . . . . . . . . . . . . . . . . . . 30
Adding or terminating a provider . . . . . . . . 39
7.4 Quantity limits . . . . . . . . . . . . . . . . . . . . . . . . . . 30
8.9 Accessibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
7.5 Step therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Access to care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
7.6 Tier lowering . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 On-call policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7.7 Electronic prior authorization. . . . . . . . . 31 Hours of operation . . . . . . . . . . . . . . . . . . . . . . . 40
7.8 Adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Limiting or closing a practice . . . . . . . . . . . . 40
Interpretation service requirements . . . . . 40
7.9 Required Medicaid Enrollment. . . . . . . . 31
Non-emergent
medical transport (NEMT) . . . . . . . . . . . . . . . 41
Section 8: Providers. . . . . . . . . . . . . . . . . . . . . . 32
8.10 Provider and member
8.1 Eligible providers. . . . . . . . . . . . . . . . . . . . . . . 32
relationship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Providers and practitioners . . . . . . . . . . . . . . 32
Dismissing IHN members . . . . . . . . . . . . . . . 42
Allied and behavioral health
care providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Open communication . . . . . . . . . . . . . . . . . . . . 42
Alternative care providers. . . . . . . . . . . . . . . . 32 8.11 Culturally competent services. . . . . . . . 43
Organizational providers . . . . . . . . . . . . . . . . . 32
Provider Manual 2Table of contents
8.12 Advance directive and declaration of 11.3 Collective Plan/Emergency
mental Department Information Exchange
health treatment. . . . . . . . . . . . . . . . . . . . . . . . 43 (EDIE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Advance directive . . . . . . . . . . . . . . . . . . . . . . . . 43 11.4 Unite us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Declaration of
11.5 eHealth Exchange . . . . . . . . . . . . . . . . . . . . . . 53
mental health treatment. . . . . . . . . . . . . . . . . . 43
8.13 Provider education . . . . . . . . . . . . . . . . . . . . . 44 Section 12: Compliance. . . . . . . . . . . . . . . . . 54
Special Needs Plan Model of Care. . . . . . . 44
12.1 Compliance and integrity program
Medicare FDR training. . . . . . . . . . . . . . . . . . . . 44
and disciplinary standards . . . . . . . . . . . . 54
Section 9: Members . . . . . . . . . . . . . . . . . . . . . . 45 12.2 Notice of Privacy Practices
and HIPAA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
9.1 Member rights and
responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . 45 12.3 Conflict of interest . . . . . . . . . . . . . . . . . . . . . 55
Samaritan Choice Plans. . . . . . . . . . . . . . . . . . 45 12.4 Fraud, waste and abuse. . . . . . . . . . . . . . . . 55
InterCommunity Health Network- Examples of fraud, waste and
Coordinated Care Organization abuse by a provider: . . . . . . . . . . . . . . . . . . . . . 55
(IHN-CCO) (Medicaid). . . . . . . . . . . . . . . . . . . . 45 12.5 Deficit Reduction Act of
Samaritan Advantage Health Plans 2005 (DRA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
(HMO) (Medicare). . . . . . . . . . . . . . . . . . . . . . . . 48
Samaritan Employer Group Plans. . . . . . . . 49 12.6 False Claims Act. . . . . . . . . . . . . . . . . . . . . . . . 56
9.2 Second opinions. . . . . . . . . . . . . . . . . . . . . . . . 49 12.7 Beneficiary Inducement Law. . . . . . . . . . 56
12.8 Exclusion checks . . . . . . . . . . . . . . . . . . . . . . . 57
Section 10: 12.9 New Preclusion List policy. . . . . . . . . . . . 57
Publications and tools . . . . . . . . . . . . . . . . . . . 50 12.10 Seclusion and restraints. . . . . . . . . . . . . . . 58
10.1 Provider directories . . . . . . . . . . . . . . . . . . . . 50 12.11 Stark Law:
10.2 Newsletters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Provider self-referrals . . . . . . . . . . . . . . . . . 58
10.3 Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 12.12 Anti-Kickback Statute (AKS). . . . . . . . . . . 58
10.4 Provider Connect. . . . . . . . . . . . . . . . . . . . . . . 51 12.13 Public health emergency. . . . . . . . . . . . . . 59
Uses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Section 13: Additional resources. . . . . 60
Assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Section 14: Glossary of terms. . . . . . . . . 61
Section 11: Health information
technology (HIT). . . . . . . . . . . . . . . . . . . . . . . . . . . 52
11.1 Health information exchange
(HIE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
11.2 Electronic health record (EHR). . . . . . . 52
Provider Manual 3Section 1: Introduction
1.1 About us Mission
Samaritan Health Plans (SHP), headquartered Building Healthier Communities Together
in the beautiful Willamette Valley, is part of an
extensive network of hospitals, doctors, clinics Vision
and caring professionals who work in tandem
Serving our communities with PRIDE
to provide organizations and individuals with
the best care and service possible. Since 2013,
Samaritan Health Services (SHS) has been ranked
Values
in the top three Healthiest Employers in Oregon Pride
according to the Portland Business Journal and Respect
one of the top 100 healthiest places to work
Integrity
in the U.S. At SHP and SHS, we take wellness
seriously and we’re proud of our award-winning Dedication
commitment. Excellence
As a dedicated wellness organization, we
believe in giving our members a greater 1.2 About this manual
role in their health. We believe in our own Samaritan Health Plans has developed this
advice, using our self-funded plan for our manual for our contracted providers. The
own employees as a proving ground for new Provider Manual along with your contract,
approaches to nurturing workplace wellness should offer guidance and resources that will
and individual well-being. And we believe in aid you in providing care to your patients/
providing local and regional coverage that our members. This manual provides crucial
understands being well embodies the whole information concerning the role and
person – body, mind, spirit, environment, responsibilities of the provider in the delivery
work, emotions, finances and community, of health care to our members and your
which are the eight aspects of wellness. patients. If you are reviewing a print copy
of this manual, please note that content is
Today, health care faces many challenges. We are
subject to change and you should refer to the
rising to meet those challenges, but not alone.
Provider Manual on the Samaritan Health Plans
We are proud of the work we are doing with our
website for the most current information.
clinician partners towards achieving the triple
samhealthplans.org/ProviderManual.
aim for health care: lower costs, better care, better
quality. And we are thankful for the thousands In addition, we suggest you visit our website
of individuals and businesses that have placed at providers.samhealthplans.org to find other
their faith in us, realizing we are reliant on each helpful tools such as provider directories,
other for greater outcomes. Each succeeding member benefits and current announcements.
when the other does. Working together towards
the same goals, towards new heights.
Provider Manual 41.3 Lines of business authorizations. Finally, providers must inform
SAHP members of any non-covered services
Samaritan Advantage Health Plans prior to being delivered and must inform
Samaritan Advantage Health Plans (HMO) members of their responsibility for payment of
(SAHP) offers four plans to eligible members: these services.
Conventional Plan, Premier Plan, Premier Plan Providers contracted with SAHP can be found
Plus and the Special Needs Plan (SNP). through the searchable directory at
Conventional Plan (HMO) is for eligible providers.samhealthplans.org/Refer-for-Care.
members who have decided not to participate in SAHP members have rights and responsibilities
Medicare Part D. These members may not enroll as described in the “Your rights and
in a stand-alone Prescription Drug Plan (PDP). responsibilities” chapter of the Evidence
This plan offers Original Medicare benefits and of Coverage. The Evidence of Coverage for
some supplemental benefits. each Advantage plan can be accessed at
Premier Plan (HMO) offers a prescription samhealthplans.org/2022Benefits. You can also
benefit (Medicare Part D) in conjunction with find this information in the member rights and
Original Medicare benefits and a variety of responsibilities section of this manual.
supplemental benefits.
Premier Plan Plus (HMO) is the enriched
InterCommunity Health Network
Advantage plan, offering the most supplemental Coordinated Care Organization
benefits. It offers all the benefits of the Premier InterCommunity Health Network Coordinated
Plan, plus more: dental benefits, hearing aids, Care Organization (IHN-CCO) was formed in
free Silver & Fit membership and coverage 2012 by local public, private and nonprofit
during the Medicare Rx drug coverage gap for partners to unify health services and systems
some tiers. for Oregon Health Plan (OHP) members in
Benton, Lincoln and Linn counties. Although
Special Needs Plan (HMO) is for Medicaid
IHN-CCO’s contract with the state of Oregon
eligible members who are also eligible for
is not exclusive, it is currently the only CCO
Medicare Part A and Part B. These members
in these three counties that administers OHP,
are dually enrolled in Medicaid and Medicare
which provides access to health insurance for
and are referred to as “duals”. They have both
Medicaid-eligible, low-income residents.
medical benefits and prescription drug benefits.
IHN-CCO offers three packages for members,
All SAHP plan benefits are subject to review for
depending on the level of care individual
medical necessity via written documentation or
members need: comprehensive (medical, mental
appropriateness of treatment setting (level of
health and dental), mental health and dental
care versus severity of condition).
and mental health only. Find out more about
Providers are required to verify that the patient plan benefits at IHNtogether.org/Your-Benefits.
is eligible on the date of service before rendering
IHN-CCO uses the OHP Prioritized List of Health
services and that the service is covered under
Services, a listing of diagnosis and treatment
the Samaritan Advantage Health Plans. The
pairings, to determine whether a diagnosis and/
provider is required to seek any necessary prior
or service is part of the OHP benefit package.
Provider Manual 5The Oregon Health Services Commission (HSC) Choice members have rights and responsibilities
designs and maintains the prioritized list under as described in the Samaritan Choice Medical
the direction of the Oregon Legislature. The and Pharmacy Handbook and the Samaritan
legislature determines the level to which the Choice Vision Handbook. For the most up-to-
list will be funded. Diagnoses and/or treatments date language, the handbooks can be accessed on
that are considered below the line are not the Samaritan website at choice.samhealthplans.
funded by the available budget set forth by org/2022ChoiceBenefits. You can also find
the Oregon Legislature and are therefore not this information in the member rights and
considered part of the OHP benefit package. responsibilities section of this manual.
IHN-CCO plan benefits are subject to review for
medical necessity via written documentation,
Samaritan Employer Group Plans
appropriateness of treatment setting (level
of care versus severity of condition) and the Samaritan Health Plans (SHP) offers employer
OHP Prioritized List condition/treatment group health plans to businesses domiciled
pair ranking. For above and below the line in the state of Oregon. View benefits for
diagnoses, please refer to the OHP Prioritized small, large and association group plans at
List of Health Services at oregon.gov/oha/hsd/ samhealthplans.org/Employers.
ohp/pages/prioritized-list.aspx. You can view all preferred providers in the
Contracted providers can be found in the provider directory by visiting our website at
searchable provider directory at providers.samhealthplans.org/Refer-for-Care.
providers.samhealthplans.org/Refer-for-Care. Samaritan employer group plans members have
IHN-CCO members have rights and rights and responsibilities as described in their
responsibilities as described in the IHN-CCO group certificates. You can find this information
Handbook. The handbook can be accessed at: in the member rights and responsibilities
providers.samhealthplans.org/Handbook. section of this manual.
You can also find this information in the
member rights and responsibilities section
of this manual.
Samaritan Choice Plans
Samaritan Health Services (SHS) offers Samaritan
Choice Plans (SCP). These are the self-funded
health benefit plans that provide coverage for
Samaritan employees and their dependents.
Samaritan Choice Plans offer a standard medical
plan, an HSA eligible high-deductible medical
plan and a vision plan. A pharmacy plan is
included with both medical plans. View plan
benefits and access our provider directory at
providers.samhealthplans.org/Refer-for-Care.
Provider Manual 6Section 2: Contact us
SHP Customer Service is available to provide In-person:
assistance Monday through Friday, from 8 a.m.
Monday through Friday, from 8 a.m. to 5 p.m.
to 8 p.m. Our representatives can:
2300 NW Walnut Blvd., Corvallis, OR 97330
z Assist with member eligibility and benefits.
z Provide claims assistance. Contact us by phone at the Customer
Service number or by email:
z Accept grievances and concerns.
healthplanresponse@samhealth.org
z Answer questions regarding authorizations.
Our Provider Relations team is here to assist
Phone: you with:
Monday through Friday, from 8 a.m. to 8 p.m.
z Credentialing questions.
at 541-768-5207 or toll free 888-435-2396.
z Contracting (existing or new).
Mail: z Provider education and training.
Samaritan Health Plans z Samaritan Health Plans provider portal:
PO Box 1310 Provider Connect.
Corvallis, OR 97339
Provider Manual 7Section 3: Claims
3.1 Eligibility and benefits 3.3 Oregon Medicaid Registration
Eligibility and benefit information for our The Oregon Health Authority (OHA) requires
members can be accessed via SHP's provider all providers who submit claims to Oregon
portal, Provider Connect, or through our Coordinated Care Organizations to be registered
Customer Service Department. Except for with the Oregon Medicaid office prior to
emergency services and as applicable, the receiving payment for services. If you have
provider shall verify each member’s eligibility not registered, you must submit application
prior to rendering any services. materials and receive an Oregon Medicaid ID
number before we can pay you. See oregon.gov/
oha/hsd/ohp/pages/provider-enroll.aspx for
3.2 General claims information forms and process.
Providers are responsible for submitting
itemized claims for services provided to
members in a complete and timely manner, 3.4 Electronic claims submission
in accordance with your provider agreement, SHP encourages providers to submit claims via
this manual and applicable law. Providers are Electronic Data Interchange (EDI) for quicker
also responsible for ensuring that all codes claims reimbursement, improved accuracy and
submitted to SHP for payment are current and to reduce or eliminate costs associated with
accurate, that the codes reflect the services mailing, such as envelopes and postage. To sign
provided and are compliant with all industry up for EDI, visit our billing and claims page at
and governmental standards. Incorrect or providers.samhealthplans.org/Submit-Claims.
invalid coding may result in delays in payment,
denial of payment, a post-payment provider
refund request or a post-payment recoupment
3.5 Electronic funds transfer (EFT)
of overpaid amounts from later payments. Samaritan Health Plans recommends that
providers receive payment via electronic funds
SHP reserves the right to review all claims transfer (EFT) for quicker payment and to avoid
submitted for accuracy and appropriateness. lost checks. Funds are deposited directly into
This review may include review of supporting your designated bank account and include the
documentation. Improper data submission may reassociation trace number (TRN), in accordance
cause claims to pend and/or be returned for with CAQH CORE Phase III Operating Rules
correction or documentation. for HIPAA standard transactions. Additional
benefits include:
z Accelerated access to funds with direct
deposit into your existing bank account.
z SHP administrates payments for IHN-CCO.
By signing up with InstaMed, you will
receive SHP payments and those for the
IHN-CCO members you see.
Provider Manual 8z Reduced administrative costs by eliminating z All claims and attachments should be
paper checks and remittances. printed single sided. Do not duplex print,
even on primary Explanation of Benefits
SHP has partnered with InstaMed to deliver this
(EOBs) or attachments.
simplified payment experience.
z Send full page attachments only.
To sign up and begin receiving electronic funds
z Do not staple claims or attachments together.
transfers (EFT), contact InstaMed at:
z Mark multi-page claims with either a page
Online: Visit InstaMed.com/ERAEFT number, i.e., page 2 of 3, or as continued.
Phone: Call InstaMed at 866-945-7990 to z Ensure that each secondary claim has the
speak with an agent. primary EOB submitted with it.
z Do not write or stamp over top of the body of
the claim form.
3.6 Electronic remittance advice
z Do not use white-out or cross out and correct
Providers can also choose to receive free electronic any fields that affect the payment of the claim.
remittance advice (ERAs) for Samaritan Health
z Use black ink — the scanning process filters
Plan payments. ERAs can be routed to your
out red ink.
existing clearinghouse through our partner
InstaMed. z Use the remarks field for messages.
z Send the original claim form to Samaritan
To sign up and begin receiving ERAs, contact
Health Plans and retain a copy for your records.
InstaMed at:
z To help our equipment scan accurately,
Online: Visit InstaMed.com/ERAEFT remove all perforated sides from the form.
Leave a quarter-inch border on the left
Phone: Call InstaMed at 866-945-7990 to
and right sides of the form after removing
speak with an agent.
perforated sides.
z Do not highlight any fields on the claim
3.7 Paper claims submission forms or attachments. Highlighting makes
For providers who submit paper claims please it more difficult to create a clear electronic
refer to the following standards to produce clean copy when the document is scanned.
and legible claims, which will reduce claim z Print with dark font. Ensure your toner or ink
rejection, speed up processing and prevent is fresh and please do not print in draft mode.
payment delays:
If you need help filling out the CMS 1450 or 1500
Where to mail paper claims
form, please see providers.samhealthplans.org/ Please see providers.samhealthplans.org/Submit-
submit-claims to review form requirements and Claims and choose File by Mail to access our
guides. current mailing addresses by line of business.
z Submit only claim forms that are typed If you submit paper claims, the following
or printed. information must be included:
z Correctly align text in the form boxes and z Provider name.
do not allow text to overlap lines.
z Rendering provider, group or billing provider.
Provider Manual 9z Federal provider TIN. z Correcting and resubmitting plan batch status
z NPI (excluding atypical providers). reports and error reports electronically.
z Medicare number (if applicable). z Correcting errors and immediately
resubmitting to prevent denials due
z DMAP number (if applicable).
to late filing.
Some claims may require additional
attachments. When submitting a paper claim,
3.9 Claims editing and pricing
please include all supporting documentation.
Claims with attachments should be submitted SHP uses claims editing software developed
on paper and attachments should be printed internally and from third-party vendors
single sided. Claims with duplex printed to assist in determining the appropriate
attachments may be sent back for correction handling and reimbursement of claims. From
and resubmission. time to time, SHP may change this coding
editor or the specific rules that it uses in
analyzing claims submissions. SHP’s goal
3.8 Monitoring submitted claims is to make sure claims are accurate and to
After filing a clean claim, the claim status ensure compliance with all state and federal
should be available in our claims adjudication rules and regulations, including those claims
system within 10 to 14 business days after payment methodologies required for Medicare
receipt. After filing a clean electronic data Advantage and OHP administration.
interchange (EDI) claim, the claim status should
SHP utilizes both the Optum EASYGroup
be available in our claims adjudication system
Prospective Payment Systems (PPS) and the
within two business days of receipt.
Claims Editing System (CES) software to ensure
After submitting paper or electronic claims, you accuracy and consistency in claims processing
can monitor them by: for all of our product lines for both professional
and facility-based claims.
z Checking claim status on our secure provider
portal at providerconnect.samhealth.org. This system applies all the existing industry
Users must be subscribers of OneHealthPort standard criteria and protocols for Diagnosis
in order to login. If you are not yet subscribed Related Groups (DRG), Current Procedural
to OneHealthPort, please register your Terminology (CPT), Healthcare Procedure Coding
organization at onehealthport.com/sso/ System (HCPCS) and the Internal Classification of
register-your-organization. Providers that Diseases (ICD-10_CM) manuals.
are not subscribed should click on “I’m not
The three most prevalent coding irregularities
an OneHealthPort Subscriber but would like
we find are:
information on subscribing”.
z Contacting Customer Service at providers. z Unbundling: Two or more individual CPT or
samhealthplans.org/Contact-Us. HCPCS codes that should be combined under
a single code or charge.
z Confirming receipt of plan batch status
reports from your vendor or clearinghouse z Mutually exclusive: Two or more procedures
to ensure your claims have been accepted that by practice standards would not be
by SHP. billed to the same patient on the same day.
Provider Manual 10z Inclusive procedures: Procedures that are IHN-CCO requires all providers to request and
considered part of a primary procedure and obtain information about third-party liability
not paid as separate services. (TPL) for payment of services and any and all
Consistent application of these rules improves the other insurance coverage to which an
accuracy and fairness of our payment of benefits. IHN-CCO member may be entitled and to
provide such information to IHN-CCO within
The software also applies the National Correct 30 days of discovery. Samaritan Health Plans
Coding Initiative (NCCI) edits for the processing also requires IHN-CCO contracted providers
of both facility and professional claims. Our to comply with OHA requests for third-party
updates of the NCCI are implemented as soon eligibility information in a timely manner.
as possible after receipt from Optum. However, The following information should be collected
these updates will not align with CMS; we will and emailed to the TPL department at
always be one version behind. shpthirdpartyinvestigation@samhealth.org:
a. The name of the third-party payer, or in
3.10 Prompt payment a case where the third-party payer has
Samaritan Health Plans follows CMS and insurance to cover the liability, the name of
OHA guidance to determine claims payment the policy holder.
timeliness for Medicare and Medicaid lines of b. The member’s relationship to the third-
business. These guidelines can be found in the party payer or policy holder.
following documents for Medicare:
c. The social security number of the third-
z Review at the Medicare Managed Care party payer or policy holder.
Appeals & Grievances webpage at cms.gov/ d. The name and address of the third-party
Medicare/Appeals-and-Grievances/MMCAG. payer or applicable insurance company.
z Medicare Claims Processing Manual Chapter e. The policy holder’s policy number for the
1, Sections 80.2 and 80.3. insurance company.
cms.gov/Regulations-and-Guidance/
f. The name and address of any third-party
Guidance/Manuals/Internet-Only-Manuals-
who injured the member.
IOMs-Items/CMS018912
Prioritized List and Guideline Notes found at
z
3.12 Balance billing
oregon.gov/oha/HSD/OHP/Pages/Prioritized-
List.aspx.
Samaritan Advantage Health Plans
The Qualified Medicare Beneficiary (QMB)
3.11 Coordination of benefits Program is available to assist low-income
and third-party liability Medicare beneficiaries with Medicare Part A and
SHP follows the National Association of Insurance Part B premiums and cost sharing, including
Commissioners (NAIC) model regulations for deductibles, coinsurances and copayments.
coordinating benefits, except in instances where
Federal law (Sections 1902(n)(3)(B) and 1866(a)
the NAIC model regulations differ from Oregon
(1)(A) of the Act, as modified by Section 4714
state law or from CMS regulations.
of the Balanced Budget Act of 1997) prohibits
In order to identify all third-party payers, all Medicare providers from billing QMBs
Provider Manual 11for all Medicare deductibles, coinsurance, to the member for services provided.
or copayments. All Medicare and Medicaid z The member has the limited Citizen Alien
payments you receive for furnishing services Waived Emergency Medical (CAWEM)
to a QMB are considered payment in full. benefit package. CAWEM members have
the benefit package identifier of CWM.
InterCommunity Health Network Members receiving CAWEM benefits may
Coordinated Care Organization be billed for services that are not part of the
CAWEM benefits. (See OAR 410-120-1210 for
A provider who is rendering services to an
coverage.) The provider must document that
InterCommunity Health Network CCO
the member was informed in advance that
(IHN-CCO) member:
the service or item would not be covered by
z May not seek payment from the member for the Division. An OHP 3165 is not required for
any Medicaid-covered services. these services.
z Cannot bill the member for a missed z The member has requested a continuation
appointment. of benefits during the contested case
hearing process and the final decision was
z May not bill the member for services or
not in favor of the member. The member
treatments that have been denied due to
shall pay for any charges incurred for the
provider error.
denied service on or after the effective date
z Cannot bill IHN-CCO more than the
on the Notice of Action or Notice of Appeal
provider’s usual charge.
Resolution. The provider must complete the
A provider may only bill an IHN-CCO member in OHP 3165 pursuant to section (3)(h) of this
the following situations: rule before providing these services.
z Any applicable coinsurance, copayment and z In exceptional circumstances, a member may
deductibles expressly authorized in OAR decide to privately pay for a covered service.
chapter 410, divisions 120 and 141 or any In this situation, the provider may bill the
other Division program rules. member if the provider informs the member
in advance of all the following:
z The member did not inform the provider
of their OHP coverage at the time of or z The requested service is a covered service
after service was provided; therefore, the and the appropriate payer (the Health
provider could not bill the appropriate payer Systems Division, Managed Care Entity
for reasons including but not limited to (MEC), or third-party payer) would
the lack of prior authorizations or the time pay the provider in full for the covered
limit to submit the claim for payment has service. The estimated cost of the covered
passed. The provider must verify eligibility service, including all related charges, the
and document attempts to obtain coverage amount that the appropriate payer would
information prior to billing the member. pay for the service and that the provider
cannot bill the member for an amount
z The member became eligible for benefits
greater than the amount the appropriate
retroactively but did not meet all the criteria
payer would pay.
required to receive the service.
z The member knowingly and voluntarily
z A third-party payer made payments directly
Provider Manual 12agrees to pay for the covered service. 3.13 Coding
z The provider documents in writing, As a contracted provider, you play an
signed by the member or the member’s important role in identifying conditions
representative, indicating the provider that impact members’ health. Please code
gave the member the information to the highest level of specificity and retain
described in section (3)(g)(A-C); that supporting documentation for each encounter.
the member had an opportunity to ask All applicable diagnosis codes should be
questions, obtain additional information included on the claim form including social
and consult with the member’s caseworker determinants of health (SDoH) and external
or representative; and that the member causes of morbidity. For more information on
agreed to privately pay for the service coding guidelines refer to your ICD-10-CM
by signing an agreement incorporating Official Guideline for Coding Manual.
all the information described above. The
provider must give a copy of the signed
agreement to the member. A provider
3.14 Timely filing
may not submit a claim for payment for Any provider billing SHP for services or
covered services to the Division or to the supplies provided to our members must adhere
member’s MCE or third-party payer that to the following timelines for reimbursement
is subject to the agreement. consideration:
z A provider may bill a member for services
that are not covered by the Division or Samaritan Advantage Health Plans
MCE. Before providing the non-covered
z Provider primary claims: Providers must
service, the member must sign the
submit clean primary claims for medical,
provider-completed Agreement to Pay
medical equipment and medical supplies per
(OHP 3165) or a facsimile containing all
the time frame stated in your contract.
the information and elements of the OHP
z Provider secondary claims: Providers
3165. The completed OHP 3165 or facsimile
must submit secondary claims within six
is valid only if the estimated fee does
calendar months of the date of the EOB for
not change and the service is scheduled
primary payment.
within 30 days of the member’s signature.
Providers must make a copy of the z Claims corrections: Corrected claims
completed OHP 3165 or facsimile available to must be clearly marked in accordance with
the Division or MCE upon request. standard billing practices and must be
received no more than 12 calendar months
from the date of service on claim, unless a
claim is reopened.
Provider Manual 13InterCommunity Health Network CCO clearly marked in accordance with standard
billing practices and must be received no
z Provider primary claims: Providers must
more than eighteen calendar months from
submit clean primary claims for medical,
the most recent process (EOB) date.
medical equipment and medical supplies per
the time frame stated in your contract.
z Provider secondary claims: Providers must
3.15 Reimbursement guidelines
submit secondary claims within six calendar SHP offers reimbursement guidelines on
months of the date of the EOB for primary our provider website to assist you with
payment. many services you may provide. To view
these guidelines please visit: providers.
z Claims corrections: Corrected claims must be
samhealthplans.org/Reimbursement.
clearly marked in accordance with standard
billing practices and must be received no
more than eighteen calendar months from
tthe most recent process (EOB) date.
Samaritan Choice Plans
z Provider primary claims: Providers must
submit clean primary claims for medical,
medical equipment and medical supplies per
the time frame stated in your contract.
z Provider secondary claims: Providers must
submit secondary claims within six calendar
months of the date of the EOB for primary
payment.
z Claims corrections: Corrected claims must be
clearly marked in accordance with standard
billing practices and must be received no
more than eighteen calendar months from
the most recent process (EOB) date.
Samaritan Employer Group Plans
z Provider primary claims: Providers must
submit clean primary claims for medical,
medical equipment and medical supplies per
the time frame stated in your contract.
z Provider secondary claims: Providers must
submit secondary claims within six calendar
months of the date of the EOB for primary
payment.
z Claims corrections: Corrected claims must be
Provider Manual 14Section 4: Care coordination
The Care Coordination Department oversees 4.2 Utilization
and monitors case management programs and management disclaimer
services to coordinate, manage and evaluate the
Samaritan Health Plans providers, staff and
delivery of health care. The scope of the care
contracted dental providers make decisions
coordination program includes all behavioral
about the care and services that are provided
health, physical and oral health care delivery
based on a member’s clinical needs, the
activities across the continuum of care,
appropriateness of care and service and the
including inpatient admissions to hospitals,
member’s coverage. SHP does not make
acute rehabilitation facilities, skilled nursing
decisions regarding hiring, promoting or
facilities (SNF), home care services, outpatient
terminating its providers or other individuals
care and office visits.
based upon the likelihood or perceived
likelihood that the individual will support or
4.1 Utilization management tend to support the denial of benefits. SHP
Prospective, concurrent and retrospective does not specifically reward, hire, promote or
reviews are performed on a case by case terminate practitioners or other individuals for
basis to determine the appropriateness of issuing denials of coverage or care. No financial
care. Utilization Management (UM) decisions incentives exist that encourage decisions that
are made by qualified licensed health care specifically result in denials or create barriers
professionals, who have the knowledge and to care or services. In order to maintain
skills to assess clinical information, evaluate and improve the health of our members,
working diagnoses and proposed treatment all providers and health care professionals
plans. Care coordination is supported by board should be especially diligent in identifying any
certified UM provider reviewers, behavioral potential underutilization of care or services.
health providers and doctoral-level practitioners
who hold a current license to practice without 4.3 Authorizations
restrictions. These licensed clinicians oversee
Care Coordination ensures accurate and timely
UM decisions to ensure consistent and
processing of prior authorization related to
appropriate medical necessity determinations.
durable medical equipment (DME), medical
Inter-rater reliability (IRR) reviews are
procedures and services including mental health
conducted to ensure consistent application of
and substance use disorder services. Utilization
the utilization criteria.
Management ensures that appropriate clinical
information is obtained, documented and
reviewed for all UM decisions. This process
may include consulting with the requesting
provider when appropriate. Authorizations may
be submitted through the Authorization Wizard
located on our online portal accessed through
Provider Connect.
Provider Manual 15To submit any type of authorization other than z Provider presents compelling
a standard request, the following conditions evidence of attempt to obtain prior
must be met: authorization in advance of the
service. The evidence shall support
z Expedited: Submission must indicate that
the provider followed SHP policy and
waiting for a decision within the standard
that the required information was
time frame could place the member’s life,
entered correctly by the provider
health or ability to regain maximum function
office into the appropriate system.
in serious jeopardy.
z Member enrollment was entered
z Retroactive: Utilization Management
retroactively in Facets and was not
follows state and federal regulations and
available at the time of service for the
contract language for review of retroactive
provider to obtain prior authorization
authorization requests. As of May 1, 2019,
from SHP.
retroactive requests will be reviewed for the
extenuating circumstances listed below. If z Requested within seven calendar
the exceptions are met, retroactive requests days of service for detoxification
are processed according to the specific line related to substance use, an initial
of business authorization request policy. If outpatient mental health evaluation,
the exceptions are not met the request will day treatment, psychiatric residential
be denied. Retroactive authorization requests treatment and subacute care.
submitted by non-contracted providers and z Requested within seven calendar days
facilities will be accepted and processed in of the dispense date for DME items
accordance with the line of business specific provided at an office visit.
authorization request policy. z Requested within 30 calendar days for
z Exceptions – Retroactive authorization DME items that require a Certificate
requests will be reviewed for medical of Medical Necessity.
necessity from contracted providers and For more information regarding authorizations,
facilities if: please visit: providers.samhealthplans.org/
z The member indicated at the time of Authorizations.
service that they were self-pay or no
coverage was in place.
z A natural disaster prevented the
provider or facility from securing
prior authorization or providing
hospital admission notification.
Provider Manual 164.4 Clinical criteria z Oregon Health Authority (OHA) Prioritized
List of Health Care Services along with
The plan’s Evidence of Coverage (EOC) or plan
Guideline Notes as published on Oregon.gov/
document and federal and state guidelines are
OHA/HSD/OHP/Pages/Prioritized-List.aspx.
used to determine benefits. Nationally recognized
criteria, federal (CMS), state, internal practice z American Society of Addiction Medicine
guidelines and company developed clinical Criteria.
standards are used to determine clinical and Clinical reviewers consider the individual
medical appropriateness of services. characteristics of the member, i.e., age,
comorbidity, complications, progress of
The criteria are selected, developed, approved and
treatment, psychosocial situation, care supports
overseen by the Care Coordination Department.
and home environment when applying criteria.
Care Coordination will ensure clinical consistency
and appropriateness of all criteria utilized by The organization gives practitioners, with
the Utilization Management team. clinical expertise in the area being reviewed,
the opportunity to advise or comment on the
Complete criteria sets are maintained
development or adoption of criteria.
electronically and are available for reference
to authorized entities, providers and members
upon request. 4.5 Medical coverage policies
The criteria utilized includes: Medical coverage policies provide clinical
criteria for decision-making and are developed
z MCG CareWebQ1 10.2 – assessment tools, when no appropriate external guidelines
review criteria and reporting. exist. Medical coverage policies do not
z Centers for Medicaid and Medicare Services determine covered benefits or whether a prior
(CMS) - Coverage guidelines, a compendium authorization is required. Medical coverage
of regulations, operation policy letters policies are made available to providers upon
and manuals that are based on medical request.
appropriateness criteria and clinical status
of the patient to support decision-making:
cms.gov/medicare-coverage-database/
4.6 Peer-to-peer consultation
overview-and-quick-search.aspx. Treating providers may request a peer-to-
peer conversation with SHP Medical Review to
z Samaritan Health Plans’ medical coverage
discuss the reason(s) for a specific denial or
policies are based on local, regional and
adverse benefit determination of services/items.
national practice standards, literature,
Peer-to-peer conversations may be requested
research and consensus-based policy.
via phone, email, fax or by visiting Samaritan
z The Oregon Health Plan (OHP), Oregon Health Plans in-person.
Administrative Rules (OAR) and Oregon
Revised Statutes (ORS) provide guidance for
interpreting IHN-CCO Medicaid benefits.
Provider Manual 174.7 Referrals for 4.8 Care management services
out-of-network services Samaritan Health Plans care management
Contracted providers are responsible for services are offered as a supplemental resource
referring members to an in-network provider; to the provider care team to assist in serving
however, members sometimes require care that members that have special health care needs,
is not available within our network of providers. such as complex behavioral, medical and oral
When this occurs, the contracted provider may health conditions and social determinants of
request a referral for the member to utilize health barriers.
an out-of-network provider or service. The
Care management services are designed to
request must indicate the reason for the medical
engage members, their families and caregivers to
necessity and the reason for the out-of-network
meet their care needs and goals and to promote
referral request, e.g., no available contracted
continuity of care and effective use of resources.
in-network provider, full provider panel or wait
Care management services are voluntary and
time to see contracted provider exceeds the
provided at no cost to the member.
medical necessity of the service. The contracted
provider referring an IHN-CCO or Samaritan
Advantage member for out-of-network services Intensive Care Coordination (ICC)
is also required to obtain all necessary prior ICC is a specialized care management program
authorizations as mandated by the plan. for members on IHN-CCO and who may have
special health care needs or are part of a
For providers making referrals for SHP
prioritized population. Examples include:
members, providers are responsible for only
referring for services covered by CMS or z Older adults: Individuals who are hard of
Samaritan Health Plans. hearing, deaf, blind or have other disabilities.
Referrals made for IHN-CCO members, must be z Members with complex or high health care
made to a Medicaid participating provider. needs: Multiple or chronic conditions, SPMI
or are receiving Medicaid-funded long-term
care services and supports (LTSS).
Out-of-state services
z Children ages zero to five: Showing early signs
For Samaritan Advantage Health Plans and
of social/emotional or behavioral problems.
IHN-CCO, SHP may give prior authorization
for non-emergency, medically appropriate, z Members with a serious emotional disorder
out-of-state services in accordance with state (SED) diagnosis.
and federal requirements. This includes, but z Members in medication assisted treatment
is not limited to, provider being enrolled as for SUD.
a current Oregon Medicaid and/or Medicare z Women who have been diagnosed with a
provider, services are not available in the high-risk pregnancy.
state of Oregon and is considered a covered,
z Children with neonatal abstinence syndrome.
medically appropriate service.
z Children in Child Welfare.
z IV drug users who have SUD and who need
withdrawal management.
Provider Manual 18z Members who have HIV/AIDS. Maternity case management
z Members who have tuberculosis. The maternity case management program’s
z Veterans and their families. primary purpose is to optimize pregnancy
outcomes, including reducing the incidence of
z Members at risk of first episode psychosis,
low birth weight babies. Services are tailored
and individuals within the intellectual and
to the individual member needs. The program
developmental disability (IDD) populations.
is available to all pregnant IHN-CCO members
and expands perinatal services to include
ICC services may include assistance to ensure
management of health, economic, social and
timely access to providers; coordination of
care to ensure consideration is given to unique nutritional factors through the end of pregnancy
needs; assistance to providers with coordination and a two-month postpartum period. A multi-
of services and discharge planning; coordination disciplinary care team consisting of a clinical
of community support such as social services. care manager, behavioral health care manager
and community health worker supports the
Members are identified through direct referrals member and her health care needs.
from contracted providers, community partners
directly engaged with the member, referrals
from utilization management, data analysis and
Complex case management
member and member representatives. The complex case management (CCM) program
is designed for members with chronic and/or
Care management staff are assigned to support
complex medical/behavioral health conditions
the member in developing an individualized
to promote independence, optimal health and
care plan (ICP.) This may begin by completing
continuity of care at the lowest cost appropriate
a health assessment. The ICP is created by and
to the member's needs. This may include
for the member to positively impact health
members with new health catastrophic event
outcomes. The ICP addresses the member’s
or prolonged hospitalizations. Together, the
clinical and social needs identified during the
nurse care manager and member establish
assessment or from the member and tracks
an individualized plan that identifies specific
the members identified goals and process
health related goals and ways to address barriers
to overcome barriers identified. The ICP is
to success. Interaction with a member’s PCP
supported by the members interdisciplinary
and relevant specialists is also an important
care team (ICT.) The team consists of internal
component of the care manager’s role. Once
and external health professionals and social
a member has been identified and agrees
supports working together to coordinate the
to participate in complex case management
member’s care. The ICT coordinates care and
program, the nurse care manager completes
develops a plan of care for high-needs members.
interventions such as the following:
The member’s primary care provider is
responsible for developing a treatment plan for
the member with the member’s participation.
The treatment plan should be in accordance
with any applicable state quality assurance and
utilization review standards.
Provider Manual 19z Completion of a telephonic assessment that Family System of Care and initiatives aimed at
includes core domains and medication review, improving access to services and quality of care.
pain assessment and depression screening.
Community health workers (CHW): CHWs work
z Members that have had a hospitalization in collaboration with the clinical care team and
are assessed for their understanding of their community partners. They assist members in
discharge instructions and follow-up care. accessing health care by connecting members
z Provider outreach for members in needs of to their PCP and helping them understand their
additional coordination or medical intervention. health plan benefits, limits and guidelines. They
z Collaboration with multi-disciplinary also are integral in coordinating community
team members such as social workers for supports and resources to reduce the barriers
community or behavioral health needs. imposed by social determinants of health.
z Member education including mailed
materials or shared resources for How to contact Care Coordination
information or support.
Contact us by phone:
Getting to know the Samaritan Monday through Friday, from 8 a.m. to 8 p.m.
Health Plans’ care team 541-768-5207 or toll free at 888-435-2396.
Nurse clinical care managers: the clinical care
manager is responsible for coordinating care in Contact us by mail:
cooperation with the PCP and other providers; Samaritan Health Plans
documenting care information and actions PO Box 1310
taken; developing an individualized care plan Corvallis, OR 97339
with the member; coordinating with member’s
care team and community resources; educating Email the SHP Care Team
members as appropriate about member
carecoordinationteam@samhealth.org
conditions, procedures and treatments and
appropriate use of plan resources.
Behavioral health care managers: The
behavioral health care manager provides
screening, knowledge of criteria and clinical
judgment to assess patient needs and assure
that medically appropriate treatment is provided
in a quality, cost-effective manner within
the benefit plan of the member. Participates
in care coordination and transition planning
for members receiving mental health services
and collaborates with community partners to
identify member needs, support service delivery,
and close gaps in members’ care. Supports
community efforts in establishing the Youth and
Provider Manual 20Section 5: Quality Management Program
Samaritan Health Plans’ Quality Management the period of one calendar year. The QI Workplan
(QM) program provides an overview of the includes quality improvement initiatives, targets,
structure and processes that enable the health measures and metrics, activities and methods of
plan to carry out its commitment to ongoing performance tracking throughout the year to meet
improvement in care and service and member regulatory requirements for each line of business.
health. Our objective is to give members
compassionate and effective care that is easily The QI Workplan:
accessible, safe, equitable and affordable. z Reviews, evaluates and monitors internal
Quality improvement goals are focused on and external data.
safety, preventive health, member and provider
z Ties specific measurements to program goals
experience and delivering excellence in care and
and objectives.
services that set community standards. The QM
program assists the organization in achieving z Outlines milestones, improvement targets
these goals. and measurements.
Samaritan Health Plans and IHN-CCO board of z Interventions are revised based on analysis
directors govern the QM program. The program findings.
integrates network providers, social service
agencies, community-based organizations, 5.2 Quality Management Council
members, health plan departments and staff at (QMC)
all levels.
Our Quality Management Council (QMC) is
The program is comprised of four core the responsible entity for the oversight and
components: management of all quality-related activities. The
QMC is chaired by the chief medical officer and
z Accreditation and standards.
is comprised of community partners and network
z Health data analytics. clinicians representing primary care, behavioral
z Quality improvement. health, oral health and specialties. SHP functional
z Patient safety. area directors and health plan staff participate
as required. The Quality Management Council
SHP demonstrates commitment to quality meets at least quarterly and provides guidance for
through continuous improvement. Our program the QM Program. It oversees quality monitoring
is ever-evolving in response to the changing and improvement activities and evaluates the
needs of our members and the standards effectiveness of key services provided to members,
established by the provider community and providers and regulatory agencies.
regulatory and accrediting bodies. Providers
can find information about our current
Quality Management program at providers. 5.3 Quality improvement projects
samhealthplans.org/QM-Program. The Quality Management program includes
numerous quality improvement projects.
The Chronic Care Improvement Program
5.1 Quality Improvement Workplan (CCIP) for Medicare Advantage members
The annual Quality Improvement (QI) Workplan ensures members with chronic conditions
governs the program structure and activities for are effectively managed. The performance
Provider Manual 21You can also read
