The following links provide information on polices, resources, pharmacy management and prior authorization.
Medicare Preventive Services
Quick Reference Chart - Preventive Services
SummaCare's claim editing software is available to providers though Plan Central. Learn more about requesting a claim adjustment or SummaCare’s claim editing software.
DME Encounter Data Companion Guide
Professional Encounter Data Companion Guide
Institutional Encounter Data Companion Guide
SummaCare provides EDI document processing for providers and employers. Learn more about EDI and how to submit HIPAA transactions to SummaCare.
SummaCare members have rights and responsibilities. Please read them carefully. These statements help ensure that members are treated by SummaCare employees and all of our contracted providers with fairness and respect. Likewise, it is important that individuals understand their responsibilities as a SummaCare member. If members do not follow these responsibilities, they may not receive all of the services or coverage to which they might otherwise be entitled.
If members have questions or concerns about their rights and protections or if they think they have been treated unfairly or their rights have not been respected, they should call SummaCare Customer Service.
View Member Rights & Responsibilities.
Even though you are a SummaCare contracted provider, your practice may not participate in every network. Learn more.
SummaCare requires prior authorization on certain drugs and services that are covered under the medical benefit. Learn more about these drugs and services requiring prior authorization.
Annually, SummaCare participates in behavioral healthcare clinical studies as part of NCQA requirements. The requirements' intent is to look at the coordination of care between medical and behavioral healthcare practitioners in order to improve health outcomes.
Coordination of Care Form
Learn more about continuity and coordination of care between medical and behavioral healthcare.
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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.
View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.