Samaritan Select

Preauthorization

• What needs to be preauthorized
• Medical preauthorization list
• Preauthorization process

Preauthorization is a tool we use to find the most appropriate and cost effective level of medical care for our member. Many types of treatment may be available for certain conditions; the preauthorization process helps your physician work together with you or your covered dependent, other providers, and Samaritan Select to determine the treatment that best meets you or your covered dependent’s medical needs. This teamwork helps save thousands of dollars in premiums each year, which translates into savings for you.

Preauthorization refers to the process by which we determine that a proposed service or supply (including medications) is medically necessary and provide approval for it before it is rendered.

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What needs to be preauthorized

Some services and supplies (as may be described in the Samaritan Services Member Handbook) must be preauthorized before the Plan will consider paying the claim. These services and supplies are listed on the Plan’s Preauthorization List below. Note that we do not preauthorize services or supplies, which are not included on the Plan’s Preauthorization List.

Preauthorization by contracting providers — Providers that have contracted with Samaritan Select know how the preauthorization process works and will normally request preauthorization, if necessary, for your or your covered dependent’s proposed service or supply.

Preauthorization by non-contracting providers — You or your covered dependent’s provider knows how this process works and will normally request preauthorization, if necessary, for you or your covered dependent’s proposed service or supply. However, if you or your covered dependent receives care from a provider with whom Samaritan Select has not contracted, you or your covered dependent may be liable for charges the Plan denies because the service or supply is not medically necessary. Avoid that risk by asking your or your covered dependent’s provider to contact the Samaritan Select Preauthorization Department.

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Medical preauthorization list

Coverage of certain medical equipment, services and surgical procedures requires Samaritan Select written authorization before the services are performed. Your provider may request preauthorization from our office by phone, fax or mail. If for any reason your provider will not or does not request preauthorization for you, you must contact Samaritan Select yourself. In some cases, additional information or a second opinion may be required before authorizing the service or procedure. More information on preauthorization requirements may be obtained by contacting our Customer Service Department at 541-768-6900 or 1-800-589-4616.

Samaritan Select Preauthorization Department
Phone: 541-768-6900 or 1-800-569-4616
Fax: 541-768-4211

Durable medical equipment (DME)

• Equipment purchase or repair with billed charges over $1,500 for any single line item or component.
• Equipment rental with billed charges over $500/month for any single line item or component.
• Extremity prosthetics with billed charges over $5,000 for any single line item or component

Inpatient services

• All out-of-area admissions from first day of stay
• Length of stay greater than 10 days
• Rehabilitation
• Skilled nursing facility (SNF)
• Transplants, ventricular assist devices (preauthorization not required for members requesting corneal transplants)

Home services

• Home health services including initial evaluations
• Home infusion therapy by providers without specific home infusion contracts
• Hospice

Other services and procedures

• Cosmetic or potentially cosmetic procedures
• Investigational or potentially investigational services
• Non-participating providers
• Obesity services including but not limited to work-up, treatment and surgery
• Orthognathic surgery
• Spinal surgery
• Hysterectomy

Notifications required

• All inpatient admissions
• Pregnancy: Providers are required to notify us of pregnancies within two weeks of the member’s first prenatal visit.

Pharmaceuticals and injectables

See the PRESCRIPTION MEDICATION PROGRAM Section of the Member Handbook or call us for information.

Chemical dependency and mental health

Samaritan Select 
Phone: (800) 569-4616
Fax: (541) 768-6900

• All Inpatient/residential
• Outpatient at 9th visit

If you receive services or procedures listed above without obtaining the required prior authorization, you will be held responsible for the expense. All preauthorizations are valid as noted or for 90 days, unless your coverage under the plan terminates before the services is performed.

If at any time you are unsure if an expense will be covered, contact Samaritan Select’s Member Services at (541) 768-6900 or 1-800-569-4616. Preauthorization is not a guarantee of payment. Benefits are always subject to patient eligibility, contract limitations, benefits used and benefit maximums effective at the time services are rendered.

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Preauthorization process

When we receive a preauthorization request from you or your covered dependent, or you or your covered dependent’s provider, we will notify you or the provider of our decision within 15 days of our receipt of the preauthorization request. However, this 15-day period may be extended an additional 15 days in the following situations:

• When we cannot reach a decision due to circumstances beyond our control, we will notify you or the provider within the initial 15-day period that the extension is necessary and when we expect to reach a decision.
• When we cannot reach a decision due to lack of information, we will notify you or the provider within the initial 15-day period that the extension is necessary, including a specific description of the additional information needed. You or your provider must provide us with the requested information within 45 days of receiving the request for additional information. Once we receive the needed information, we will notify you of our decision within 48 hours after you supplied it to us or at the end of the period we allowed you to supply the needed information to us.

Our Preauthorization department may be reached by phone or mail at:

• Mail:
  Samaritan Select
  PO Box 1310
  Corvallis, OR 97339-1310
• Telephone:
  541-768-6900
  Toll-free: 1-800-569-4616
• Fax:
  541-768-4212

If we approve a preauthorization request from a provider, we are bound to cover the authorized service or supply as follows:

• If your or your covered dependent’s coverage terminates within five business days of the preauthorization date, we will cover the preauthorized service or supply if the service or supply is actually incurred with
  in those five business days regardless of the termination date unless we are aware the coverage is about to terminate and we disclose this information in our written preauthorization. In that case, we will only cover the preauthorized service or supply if incurred prior to termination.
• If your or your covered dependent’s coverage terminates later than five business days after the preauthorization date, but before the end of 30 calendar days, no service incurred after termination will be covered even if preauthorized.
• If coverage remains in effect for at least 30 calendar days after the preauthorization, we will cover the preauthorized service or supply if incurred within the 30 calendar days.
• When counting the days described above, day one will begin on the calendar or business day after we preauthorized the service or supply.