Utilization Management

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:
  • eviCore Healthcare High Tech Radiology Criteria
  • Centers for Medicare and Medicaid coverage criteria
  • Hayes, Inc.
  • McKesson InterQual Adult and Pediatric Procedures Criteria
  • McKesson InterQual Behavioral Health Guidelines
  • McKesson InterQual Imaging Guidelines
  • MCMC (managing care managing claims) review
  • National Comprehensive Cancer Network (NCCN) Guidelines
  • Plan developed Guidelines
  • Pharmacy and Therapeutics Committee Guidelines
  • McKesson Interqual Level of Care Criteria – for acute inpatient, long-term acute care, inpatient rehabilitation, and skilled nursing care
  • McKesson InterQual Behavioral Health Care Criteria – for all levels of behavioral health and chemical dependency care
  • Alere-Neonatal Clinical Management Guidelines
  • Reference Approved Criteria listed above
  • McKesson Interqual Homecare Criteria
  • McKesson Interqual Durable Medical Equipment (DME) Criteria
  • DME Medicare coverage criteria for Medicare
  • Peer Literature Review (where criteria are not otherwise available)
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 appropriateness of care and service and existence of coverage. 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 receives routine and expedited/urgent requests to authorize services between 8:30 am to 5:00 pm at 330-996-8710 or 888-996-8710 (TDD/TTY 800-750-0750). 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. Language assistance is available for members to discuss issues or questions related to authorizations or utilization management.   

If you have any questions regarding SummaCare’s Utilization Management Program, please call Customer Service at 330-996-8700 or 800-996-8701 (TTY 800-750-0750). A Customer Service representative will direct your questions to the appropriate Utilization Management personnel. Members may also obtain the medical criteria used in making a determination by calling 330-996-8775 or 888-996-8710 and requesting the information.