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 Medical Policy Committee reviews and approves the development of UM criteria. The Medical Policy Committee consists of primary care and specialty physicians/practitioners who currently provide direct patient care. The SummaCare Medical Policy Committee reviews and updates medical criteria for UM decision making on an annual basis. SummaCare approved criteria include, but are not limited to:

  • Centers for Medicare and Medicaid coverage criteria
  • eviCore Healthcare High Tech Radiology Criteria
  • Hayes, Inc.
  • Internally Developed Clinical Practice Guidelines
  • McKesson InterQual Adult and Pediatric Criteria 
  • McKesson Interqual Behavioral Health Guidelines (includes Adult, Geriatric, Child & Adolescent Psychiatry, Residential & Community-Based Treatment, Substance Use Disorders & Dual Diagnosis)
  • McKesson InterQual Durable Medical Equipment (DME) Criteria
  • McKesson InterQual Homecare Criteria 
  • McKesson InterQual Imaging Guidelines 
  • McKesson InterQual Level of Care Acute Adult and Pediatric, Subacute/Skilled Nursing Facility, Long Term Acute Care, and Rehabilitation
  • MCMC (managing care managing claims) review
  • National Comprehensive Cancer Network (NCCN) Guidelines
  • National Evidence-Based Peer Reviewed Medical Organization Recommendations and/or Peer Literature Review
  • Pharmacy and Therapeutics Committee Guidelines
  • Reference Approved Criteria listed above
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, 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. 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). SummaCare does not make decisions regarding hiring, promoting or terminating its practitioners or other individuals conducting utilization review based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.

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 request to authorize services from 8:30 a.m. to 5:00 p.m. 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. Routine requests to authorize services can be faxed to 234-542-0815 using the Prior Authorization Request Form for services.

For urgent/expedited request, call 330-996-8710 or 888-996-8710 (TDD/TTY 800-750-0750).

SummaCare also maintains a voice mailbox to receive requests for authorizations outside of regular business hours. Communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day. Language assistance is available free of charge, for members to discuss issues or questions related to authorizations or utilization management

Authorization Resources

Physicians/Practitioners may obtain a copy of the benefit provision or the medical necessity criteria used in making a determination by calling the number(s) below and requesting the information. 
  • High-Tech Radiology criteria: 1-855-774-1315
  • Ambulance criteria: 330-996-8791 or 866-996-8791
  • All other criteria requests: 330-996-8775 or 888-996-8710 or email contactproviderservices@summacare.com
Medical necessity criteria are also available online via Plan Central. Physicians/Practitioners may speak to a Medical Director regarding decision based on medical necessity by calling 330-996-8775 or 888-996-8775. For general utilization management questions, call Provider Support Services at 330-996-8400 or 800-996-8401 or email contactproviderervices@summacare.com.

If you have any questions regarding SummaCare’s Utilization Management program, please call SummaCare Medicare Customer Service at 330-996-8885 or 800-996-6520 (TTY 800-750-0750). A Customer Service representative will direct your questions to the appropriate Utilization Management personnel.