Affirmative Statement About Incentives
SummaCare bases utilization management (UM) decisions on reasonable medical evidence and consensus of relevant healthcare professionals. Clinical decisions about each request for service are based on the clinical features of the individual case and the medical necessity criteria.
SummaCare uses medical necessity criteria to help determine the appropriateness of the care or service. The SummaCare Quality Value Committee (QVC) reviews and approves the development of UM criteria. The QVC consists of primary care and specialty physicians/practitioners who currently provide direct patient care. The SummaCare QVC reviews and updates medical criteria for UM decision making on an annual basis. SummaCare approved criteria include, but are not limited to:
- Milliman Care Guidelines (Inpatient and Surgical Care) - the first line criteria for evaluation of inpatient medical services
- InterQual Behavioral Health Guidelines - the first line criteria for evaluation of behavioral health services
- InterQual’s Imaging Criteria - the first line criteria for evaluation of medical necessity for imaging procedures
- Interqual Guidelines (Procedures-Adult, Procedures-Pediatric, Imaging) - the first line criteria for evaluation of medical necessity for outpatient procedures and surgical services
- Alere Neonatal Guidelines - the criteria used for high-risk newborns cared for in neonatal intensive care
- The Center for Medicare and Medicaid Services (CMS) Guidelines
- Health Plan Benefits and Coverage Guidelines including clinical practice guidelines and medical necessity criteria
SummaCare is sensitive to the risks of underutilization of care and service which include inappropriate or delayed treatment, preventable contraction of disease, extended duration and/or exacerbation of symptoms, undetected progression of disease, misdiagnosis, impaired quality of life and permanent loss of function and preventable death. For this reason, SummaCare distributes annually, an affirmative statement to all of its practitioners, providers, staff and members regarding its incentives to encourage appropriate utilization and discourage underutilization.
SummaCare does not reward physicians/practitioners or other individuals conducting utilization review for issuing denials of coverage or service. UM decision-making is based only on the existence of coverage and appropriateness of care and service. Financial incentives for UM decision makers do not encourage decisions that result in underutilization – e.g. SummaCare does not use incentives to encourage barriers to care and service.
Several factors can delay or even prevent the authorization of care of services. These include late referrals, missing referrals, referrals to out-of-network practitioners/providers and incomplete clinical data. Your efforts to avoid these pitfalls will improve the satisfaction of your SummaCare patients and allow the processing of their care authorizations to progress smoothly. SummaCare maintains an incoming fax line available 24 hours a day, 365 days a year dedicated to receiving incoming authorization requests.
SummaCare also maintains a voice mailbox to receive requests for authorizations outside of regular business hours. The fax line and voice mailbox are non-monitored outside of regular business hours, thus items faxed after close of business are considered to be received on the next business day.
Physicians/Practitioners may obtain the medical criteria used in making a determination by calling 330-996-8775 or 888-996-8710 and requesting the information. Medical criteria are also available online via PlanCentral. Physicians/Practitioners may speak to a Medical Director regarding decisions based on medical necessity by calling 330-996-8775 or 888-996-8710.
For general utilization management questions, call Provider Support Services at 330-996-8400 or 800-996-8401.