This webpage is to help you understand your Medicare Advantage medical benefits and what procedures and/or services require prior authorization by SummaCare.
The Prior Authorization Code “look up”, criteria, and utilization and/or clinical policies provided on this website are intended to help interpret SummaCare Medicare Advantage Evidence of Coverage (EOC) documents. When determining coverage, the member-specific EOC will always govern.
Before using this webpage or links, please check the member-specific EOC and any applicable federal or state mandates. SummaCare follows all Centers for Medicare and Medicaid Services (CMS) rules and regulations pertaining to all Medicare Advantage plans. Unless otherwise stated, all SummaCare policies are appropriate to Medicare Advantage plan members.
SummaCare reserves the right to modify its policies as necessary. SummaCare Clinical Policies are intended to be used in alignment with CMS rules and regulations with the independent professional medical judgment of a qualified healthcare provider and do not constitute the practice of medicine or medical advice. Policies found on this website are provided for informational purposes.
SummaCare may also use third-party tools, such as the InterQual® criteria, to assist in administering health benefits. These tools will support all CMS requirements for Medicare Advantage plans.
Utilization management (UM) is a process health plans use to evaluate the medical necessity, appropriateness and efficiency of healthcare services, procedures and facilities. UM is used to prevent unnecessary or inappropriate care. Some healthcare services require review and authorization by the health plan. SummaCare bases all authorization (concurrent or inpatient, prior authorization and post service) decisions on reasonable medical evidence and a 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.
Prescription drug benefits incorporate utilization management programs that apply restrictions on certain drugs. These restrictions include, but are not limited to, prior authorization, step therapy and quantity limits.