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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:

Applied Behavioral Analysis
Computer Assisted Surgical Navigational Procedure
Drug Testing in the Outpatient Setting
Evaluation of New and Existing Technologies
Genetic Testing
Proprietary Laboratory Analyses
Psychiatric Sub-Acute Admission
Wireless Gastrointestinal MonitoringSystem