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. Authorizations are processed as standard (14 business days) or expedited (72 hours from receipt of request). 

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

2017 Samaritan Advantage Prior Authorization List

Prior Authorization Form (except DME and Imaging)

DME Prior Authorization Form

Imaging Authorization and Referral Form

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

(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

(For plans with an effective date between 1/1/2016 and 12/31/2016. Verify a member’s effective date on provider portal, Provider Connect.) 

2016 Samaritan Standard, Health & Well-Being, and New Performance Prior Authorization List

2016 Samaritan Everyday Choices Prior Authorization List

2016 Samaritan Momentum Authorization List

Prior Authorization Form(except DME and Imaging)

DME Prior Authorization Form

Imaging Authorization and Referral Form

Samaritan Choice Plans for Employees of Samaritan Health Services

2017 Samaritan Choice Prior Authorization List

Prior Authorization Form (except DME and Imaging)

DME Prior Authorization Form

Imaging Authorization and Referral 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.