Member FAQs

Many advanced procedures, inpatient admissions and certain medications require prior authorization. Requirements vary by plan. Learn more about prior authorization metrics. For more information, call Member Services at 330.996.8885 (TTY 711).

 

Members can contact Member Services at 330.996.8885 (TTY 711) or their provider’s office to obtain status updates on authorization requests.

Processing times vary based on the service requested and whether additional clinical information is needed. Learn more about prior authorization metrics. For more information, call Member Services at 330.996.8885 (TTY 711).

Your healthcare provider typically submits clinical records, diagnosis information and treatment details for review. Learn more about prior authorization metrics. For more information, call Member Services at 330.996.8885 (TTY 711).

Claim status can be viewed through Plan Central or by contacting Member Services at 330.996.8885 (TTY 711).

Most claims are processed within 30 to 45 days after they are received. Once a claim is processed, you will receive an Explanation of Benefits (EOB) showing how the claim was handled and any amount you may owe.


If you have questions about a claim or it has been more than 45 days since submission, please contact Member Services at 330.996.8885 (TTY 711) for assistance.

 

Claim payment details are available on your Explanation of Benefits (EOB). EOBs can be found on Plan Central. For assistance, contact Member Services at 330.996.8885 (TTY 711).

An Explanation of Benefits (EOB) is a statement that explains how a claim was processed, what services were billed, what your plan paid and what amount, if any, you may owe. An EOB is not a bill, but it can help you understand any charges you receive from a provider.

If you have questions about your EOB or claim, contact Member Services at 330.996.8885 (TTY 711) for assistance.

 

You may still be responsible for out-of-pocket costs such as deductibles, copayments, coinsurance or services not covered by your plan. Review your Explanation of Benefits (EOB) to see how your claim was processed and what amount, if any, you owe.

If you have questions about a bill or your coverage, contact Member Services at 330.996.8885 (TTY 711) for assistance.

Members may submit complaints regarding service concerns or other member experience matters. Learn more about filing a complaint or contact Member Services at 330.996.8885 (TTY 711).

If a concern remains unresolved, additional review and escalation processes may be available. Learn more about our appeals and grievances process or contact Member Services at 330.996.8885 (TTY 711).

Learn more about our appeals and grievances process. If you have questions about appeals or grievances, contact Member Services at 330.996.8885 (TTY 711).

 Some plans require referrals for specialist visits. Review your plan benefits or contact Member Services at 330.996.8885 (TTY 711) to determine your requirements.

Certain services, procedures, medications and treatments require prior authorization. To verify, call Member Services at 330.996.8885 (TTY 711).

Coverage varies by plan. Medicare Advantage members can use the Scout chatbot to see if a service, procedure or treatment is covered or call 330.996.8885 (TTY 711).

Your cost depends on your plan's deductible, copayment, coinsurance and network status. Medicare Advantage members can refer to their plan documents or use the Scout chatbot to confirm plan-specific copay amounts. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Claims may be denied for several reasons, including eligibility issues, missing information, noncovered services or lack of required authorization. To learn more, contact Member Services at 330.996.8885 (TTY 711). Click here if you are looking for Appeals and Grievances information. 

Forms, provider search tools, plan documents and member resources are available for Medicare Advantage members through the Resources and Member sections of summacare.com/medicare-members/member-resources. 
If you are having trouble finding a specific document or resource, contact Member Services at 330.996.8885 (TTY 711) for assistance.

 

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If you’re still experiencing issues, contact Member Services at 330.996.8885 (TTY 711) for assistance. 

 

You may be able to cancel or disenroll from your plan during certain enrollment periods or under specific circumstances, depending on your coverage type and eligibility. Disenrollment requests for Medicare Advantage members, must follow plan and Medicare guidelines, when applicable.

To learn about your options and the steps required to cancel your coverage, contact Member Services at 330.996.8885 (TTY 711). A representative can explain your disenrollment rights, effective dates and any potential impact on your coverage.

 

Medicare-eligibles can enroll in a Medicare Advantage plan during the Annual Enrollment period or 3 months prior to their 65th birthday. Those not eligible for Medicare Advantage plans and who do not have coverage through an employer, can enroll in an Individual & Family plan during a qualifying life event or during the Open Enrollment Period.

You can enroll online, by phone or through a licensed agent during an eligible enrollment period at 330.996.8885 (TTY 711).

 

The Medicare Advantage Annual Enrollment Period (AEP) takes place each year from October 15 through December 7. During this time, eligible individuals can review their coverage and make changes to their Medicare health and prescription drug plans for the following year.


If you have questions about your Medicare Advantage options or need help selecting a plan, contact a SummaCare Medicare Advantage Advisor at 888.469.1010 (TTY 711).

 

You can generally change your health plan during an eligible enrollment period or after a qualifying life event that triggers a Special Enrollment Period (SEP).

To make a Medicare Member plan change, visit summacare.com/medicare-members/change-your-plan. Or change your plan over the telephone by calling toll free 866.262.4410 (TTY 711).

 

Depending on your income and eligibility, financial assistance programs may be available to help with Medicare premiums, prescription drug costs and other healthcare expenses. Contact Member Services at 330.996.8885 (TTY 711) to learn about available programs and resources.

Extra Help is a federal program that helps eligible Medicare beneficiaries pay for prescription drug costs, including premiums, deductibles and copayments. Eligibility is based on income and resources.

 

Medicare Savings Programs help eligible individuals pay Medicare premiums and, in some cases, deductibles, coinsurance and copayments. Eligibility is based on income and other requirements.

Yes. Plan documents, handbooks and coverage materials can be accessed on Plan Central or requested by mail. For assistance call Member Services at 330.996.8885 (TTY 711).

 

Yes. Accessible formats and language assistance may be available upon request, including materials in large print and certain alternative languages.

To request materials in an accessible format or another language, please contact Member Services at 330.996.8885 (TTY 711). We can help ensure you receive information in a format that meets your needs.

 

Plan documents are available through Plan Central, where you can view and download important coverage materials, forms and plan information.

If you need help accessing Plan Central or locating a specific document, contact Member Services at 330.996.8885 (TTY 711) for assistance.

 

Members can request a replacement ID card online, through Plan Central or by contacting Member Services at 330.996.8885 (TTY 711)

 

Members can log in to their SummaCare member account to view medical benefits, check claims, review prescription coverage details and find pharmacy information. Members who would like to learn more about Care Management programs can also call 330.996.8931 or 877.888.1164 (TTY 711) during business hours.

Care Management connects members with registered nurse Care Managers who help coordinate care between providers, hospitals and home settings. Care Managers can assist patients in understanding their medical conditions, arrange services, help with transitioning patients from hospital to home and connect members to community resources. Licensed social workers are also available to help with support services such as transportation or community assistance.

SummaCare offers several programs to support members in managing their health and wellness needs. These include Care Management for complex or ongoing health needs, Pregnancy Care for high-risk expectant mothers, Health Coaching to support lifestyle improvements and wellness tools such as WebMD® Health Manager. These programs and tools are designed to help members stay healthy, manage conditions and access the care and resources they need.

SummaCare supports our members by providing access to a variety of wellness tools and services, including preventive health reminders for both screenings and wellness visits, Health Coaching, the 24-Hour Nurse Line for health questions, wellness discounts through HUSK and vision discounts through EyeMed®. Members can also receive an annual flu vaccine at no cost from participating in-network providers or pharmacies.

Generic medications or preferred formulary options may help lower prescription costs. To learn more, contact Member Services at 330.996.8885 (TTY 711).

Some medications require prior authorization before coverage can be approved. Learn more about prior authorization metrics. For more information, call Member Services at 330.996.8885 (TTY 711).

Many plans include convenient mail-order options for maintenance medications. To learn more, contact Member Services at 330.996.8885 (TTY 711).

Prescription costs depend on the medication tier, pharmacy used and your pharmacy benefits. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Prescription coverage depends on your plan's formulary (drug list). Search the formulary or contact Member Services for assistance at 330.996.8885 (TTY 711).

You can search for participating pharmacies using the online pharmacy locator. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Visit the Plan Central member portal and enter your username and password. If you're having trouble signing in, use the password reset tool. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Select the "Forgot Username" or "Forgot Password" option on the Plan Central login page and follow the instructions to recover your account. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Members can view benefits, claims, ID cards, plan documents and other information through Plan Central. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Your documents may not be available due to account access issues or a temporary system problem. Log out and back in, or contact Member Services for assistance at 330.996.8885 (TTY 711).

Most plans allow you to select or change your PCP. You can change your PCP here or by contacting Member Services at 330.996.8885 (TTY 711).

The provider directory allows you to search by specialty, location and provider name. For more information, contact Member Services at 330.996.8885 (TTY 711).

Use the Find a Provider tool to search for providers, specialists, hospitals and urgent care centers. For assistance, contact Member Services at 330.996.8885 (TTY 711).

To confirm that your provider is in network, search the provider directory for the most current information. For assistance, contact Member Services at 330.996.8885 (TTY 711).

Please note that provider participation can change.

 

Covered urgent care facilities can be found using the online provider search tool or by contacting Member Services at 330.996.8885 (TTY 711).

If you're shopping for a Medicare Advantage plan, visit our Shop Medicare page and enter your ZIP code to view and compare plans based on your healthcare needs and budget.


If you're looking for Individual & Family coverage, visit our Shop Individual & Family section and select "Get a Quote" to explore and compare available plan options.

 

If you need assistance choosing a plan, speak with a licensed representative toll free at 330.996.8885 (TTY 711). We're available to help you find the coverage that's right for you.

Costs vary by plan type, coverage level, age and eligibility for financial assistance. For more information, view our Medicare Advantage and our Individual & Family options. If you need assistance, speak with a licensed representative toll-free at 330.996.8885 (TTY 711)

SummaCare offers Medicare Advantage plans, Individual & Family plans and employer group products. Availability depends on where you live, your eligibility and enrollment status. Explore plans online or speak with a licensed representative toll free: 330.996.8885 (TTY 711)

You can enroll during an eligible enrollment period, including the Annual Enrollment Period (AEP), Open Enrollment Period (OEP) or after a qualifying life event that triggers a Special Enrollment Period (SEP).

 
Enrollment periods:

• Marketplace Open Enrollment: November 1 to December 15 for a January 1 effective date, December 16 to January 15 for a February 1 effective date.
• Marketplace Special Enrollment: January 16 to October 31 (for individuals who qualify due to a life event)
• Medicare Annual Enrollment Period (AEP): October 15 to December 7
• Medicare Special Enrollment Period (SEP): December 8 to October 14 (for eligible individuals)
  

For more information or assistance with enrollment, contact Member Services at 330.996.8885 (TTY 711).

 

Use the provider search and drug lookup tools to check whether your providers and medications are covered under a specific plan.