You have the option to submit authorizations online through your provider portal, Provider Connect.
Appeal Request Form
Case Management Referral Form
Hepatitis C Therapy Prior Authorization Form
Medication Redetermination Form
Member Request to Change PCP Form
Part D Vaccine Reimbursement Form
Prescription Mail Order Transfer Form – to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Waiver of Liability Statement – Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless in order to request a reconsideration of the plan’s denial of payment. The reconsideration must be filed within 60 calendar days from the remittance notification.
You have the option to submit authorizations online through your provider portal, Provider Connect.
You have the option to submit authorizations online through your provider portal, Provider Connect.
You have the option to submit authorizations online through your provider portal, Provider Connect.
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Select medications may require prior authorization. A physician may submit authorization requests by:
You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.
When you think about wellness do you think only about your body? Many things affect wellness. There are eight aspects to your "life-health."
Choice, Employer Group & IHN-CCO members call 541-768-4550 or 800-832-4580 (TTY 800-735-2900). Samaritan Advantage members call 541-768-7866 or 866-207-3182 (TTY 800-735-2900). Sales agents are available. Hours: Monday through Friday, 8:30 a.m. to 5 p.m.
Customer Service is available. Hours: Monday through Friday, 8 a.m. to 8 p.m.
Samaritan Advantage Plans members only: From Oct. 1 to March 31, Customer Service is available daily from 8 a.m. to 8 p.m.
Samaritan Advantage Health Plan is an HMO with a Medicare and Oregon Medicaid contract. Enrollment in Samaritan Advantage Health Plan depends on contract renewal. Other providers and pharmacies are available in our network. This information is not a complete description of benefits. Call 866-207-3182 (TTY: 800-735-2900) for more information. Limitations, copayments or restrictions may apply. Contact the plan for more information. Benefits, copayments or co-insurance may change on January 1 of each year. The pharmacy and/or provider network or formulary may change at any time. You will receive notice when necessary. Samaritan Advantage Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
Samaritan Advantage HMO plans are available only in Benton, Lincoln and Linn County, Oregon.
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