Samaritan Select

Preauthorization

Coverage of certain medical services and surgical procedures requires Samaritan Choice Plans’ written authorization before the services are performed. Your provider may request preauthorization by phone, fax, or mail. If for any reason your provider will not or does not request preauthorization for you, you must contact Samaritan Choice yourself. In some cases, additional information or a second opinion may be required before authorizing coverage.

Preauthorization by Samaritan Choice is required for the following medical services and surgical procedures:

• Hysterectomy
• Tonsillectomy and adenoidectomy
• Neck and back surgery
• Sclerotherapy
• Cosmetic and reconstructive surgery
• Gastric bypass surgery
• Transplant services (except corneal)
• Artificial limbs and eyes
• Hospitalization for dental procedures
• Hospitalization  beyond 5 days
• Inpatient rehabilitative services
• PET scans
• Home health
• Outpatient cardiac rehab
• Outpatient and non-emergent MRI
• Outpatient surgery performed at an ambulatory surgical center
• Pain management clinics/Multidisciplinary programs
• Skilled nursing facility services
• Mental health and chemical dependency inpatient and residential services
• Outpatient mental health and chemical dependency counseling beyond 10 sessions
• Certain medical equipment, including insulin pumps and any durable medical equipment over $1,000 in rental or purchase fees or rental over three months
• Preferred benefits at non-preferred facilities and/or providers

If you receive any of the services or procedures listed above without obtaining the required preauthorization, you will be held responsible for the expense. All preauthorizations are valid as noted or for 90 days, unless your coverage under the plan terminates before the service is performed. If at any time you are unsure if an expense will be covered, contact the Samaritan Choice Plans at (541) 768-5216 or 1-866-300-4100. For pharmacy questions please call (541) 768-5207 or 1-888-435-2396.

Preauthorization is not a guarantee of payment. Benefits are always subject to patient eligibility, contract limitations, benefits used and benefit maximums effective at the time services are rendered.