Authorizations

Prior Authorization Lists and Forms

The Utilization Management team manages authorization requests made on behalf of our members. This includes medical, surgical, mental health and addiction medicine requests for inpatient, rehabilitation, DME and other specialty services requiring an authorization for the plan. Services or items requiring an authorization are identified in the plan documents and listed here by plan. 

You Can Request an Authorization Electronically

Visit your provider portal, Provider Connect, to submit and track your authorizations online.

Samaritan Advantage Health Plan HMO - Conventional, Premier, Premier Plan Plus, Special Needs Plan

2018 Samaritan Advantage Prior Authorization List

Prior Authorization Form (except DME and Imaging)

DME Prior Authorization Form

Imaging Authorization and Referral Form

SNF/LTAC/Acute Rehab Authorization Form

Samaritan Standard, Health & Well-Being, Momentum, New Performance, and Everyday Choices

2018 Authorization Lists

(For plans with an effective date between 1/1/2018 and 12/31/2018. Verify a member’s effective date on provider portal, Provider Connect.)

2018 Samaritan Standard, Health & Well-Being, and New Performance Prior Authorization List

2018 Samaritan Everyday Choices Prior Authorization List

2018 Samaritan Momentum Authorization List

2017 Authorization Lists

(For plans with an effective date between 1/1/2017 and 12/31/2017. Verify a member’s effective date on provider portal, Provider Connect.)

2017 Samaritan Standard, Health & Well-Being, and New Performance Prior Authorization List

2017 Samaritan Everyday Choices Prior Authorization List

2017 Samaritan Momentum Authorization List

Forms

Prior Authorization Form(except DME and Imaging)

DME Prior Authorization Form

Imaging Authorization and Referral Form

SNF/LTAC/Acute Rehab Authorization Form

Request Rx Prior Authorization

Select medications may require prior authorization. A physician or member may request authorization.

Rx Prior Authorization Form

Talk with our Provider Services representatives 

call us at 541-768-5207 1-888-435-2396 8 a.m. to 6 p.m.
Mon. - Fri.