Effective May 1, 2019, Samaritan Health Plans will not review any retroactive requests for medical necessity unless the request meets one or more of the following exceptions:
- The member indicated at the time of service that they were self-pay or no coverage was in place.
- A natural disaster prevented the provider or facility from securing prior authorization or providing hospital admission notification.
- Provider presents compelling evidence of attempt to obtain prior authorization in advance of the service. The evidence shall support the provider followed SHP policy and that the required information was entered correctly by the provider office into the appropriate system.
- Member enrollment was entered retroactively in Facets and was not available at the time of service for the provider to obtain prior authorization from SHP.
- Requested within 7 calendar days of service for detoxification related to substance use, an initial outpatient mental health evaluation, day treatment, psychiatric residential treatment and subacute care.
- Requested within 7 calendar days of the date dispensed for DME items provided at an office visit.
- Requested within 30 calendar days for DME items that require a Certificate of Medical Necessity.
Review the full policy: Retroactive Authorization Requests Policy