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Utilization Management

SummaCare bases utilization management (UM) decision-making only on appropriateness of care and service and existence of coverage. Decisions are based 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 committee consists of primary care and specialty physicians/practitioners who currently provide direct patient care. They review and update medical criteria for UM decision making on an annual basis. SummaCare-approved criteria includes, but is not limited to:

  • Centers for Medicare and Medicaid Services (CMS) Guidelines
  • Health Plan Benefits and Coverage Guidelines including Clinical Practice Guidelines and medical necessity criteria
  • Change Healthcare InterQual Imaging Guidelines
  • Change Healthcare InterQual Behavioral Health Guidelines
  • Change Healthcare InterQual Adult and Pediatric Procedures Criteria
  • Change Healthcare InterQual Level of Care Acute Adult and Pediatric Criteria (including acute care hospital, long-term acute care hospital, inpatient Rehabilitation, skilled nursing criteria)
  • Change Healthcare InterQual DME Criteria
  • Change Healthcare InterQual Home Care Criteria
  • Change Healthcare InterQual Medicare Procedures Criteria
  • eviCore Healthcare High Tech Radiology Criteria
  • Pharmacy and Therapeutics Committee
  • Peer Literature Review
  • Plan Developed Criteria
  • MCMC (managing care managing claims) review
  • Hayes, Inc. New Technology Criteria
  • eviCore High Tech Radiology and Oncology(Medical Oncology, Radiation Oncology, Lab/Genomic testing)

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 an affirmative statement annually to 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. 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 or missing authorization requests, 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 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 requests 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 or emailing as listed below and requesting the information.

Physicians/practitioners may speak to a Medical Director regarding decisions based on medical necessity by calling 330.996.8775 or 888.996.8775.

Questions?  We are here to help.

Provider Support Services

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Provider Engagement Specialists

If you have not met with your assigned Provider Engagement Specialist or would like to schedule an in-office training or meeting to address any questions regarding the authorization process, claims issues, appeals, SummaCare products/benefits or Plan Central training, please contact the assigned Provider Engagement Specialist for your office.

Plan Central

View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.