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.
View SummaCare’s Internal Medical Policies to better understand the coverage guidelines and clinical criteria used for certain medical services, procedures and treatments under Medicare Advantage plans. These policies help support consistent, evidence-based coverage decisions for members and providers. Explore the current policies and access additional details about specific healthcare services and technologies.
Learn more about SummaCare’s policies related to medical coverage, benefits and healthcare services for Medicare Advantage members. These policies are designed to help members and providers better understand how certain services and treatments are reviewed and covered. Explore policy details and access helpful information to support informed healthcare decisions.
Some healthcare services and treatments may require prior authorization before coverage is approved under your Medicare Advantage plan. This page provides information about SummaCare’s prior authorization process, including forms, requirements and helpful resources for members and providers. Review the details to better understand when prior authorization may be needed and how to request it.
View information about Medicare prior authorization metrics for medical items and services, including details related to authorization requests, approvals and coverage determinations. This page is designed to provide transparency into the prior authorization process and help members better understand how certain healthcare services and treatments are reviewed.
SummaCare uses utilization management criteria to help review requests for authorization or preauthorization and determine whether requested care or services are appropriate and medically necessary. These criteria may include CMS guidelines, plan benefit documents, InterQual®, eviCore and other approved medical policy resources.
Before using these resources, members should review their member-specific Evidence of Coverage and any applicable federal or state requirements.
| Season | Days | Times |
|---|---|---|
| Oct 1 – Mar 31 | 7 days a week | 8:00 a.m. – 8:00 p.m. |
| Apr 1 – Sep 30 | Mon – Fri | 8:00 a.m. – 8:00 p.m. |
Outside these hours, you may leave us a message and a representative will return your call the next business day.