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Prior Authorization Services

Prior Authorization Services

SummaCare utilizes one prior authorization list for all fully-insured PPO health insurance plans and Medicare plans. Please use the forms below when requesting prior authorization for these services. These forms include the information which is necessary for a prior authorization determination.

Please note: More information may be requested upon your completion and submission of the applicable form(s).

Applicable to requests submitted via Plan Central for Commercial and Marketplace plans: Determinations and responses for requests submitted electronically will be made within 48 hours for urgent requests and 10 calendar days for non-urgent requests from the time the request is received by SummaCare with all information necessary to support the prior authorization request.

To view prior authorization lists for self-funded groups, please visit Plan Central and click on "Related Documents" after logging in.

COVID 19 Response: SummaCare Hospital Floor to SNF Program

Program ends 4/30/2022
The SummaCare Hospital Floor to SNF Program is ending 4/30/2022. All SNF’s and Hospitals should return to following SummaCare Prior Authorization processes for SNF Admission beginning 5/1/2022.

For questions, please call 330.996.8625.

After-Hours Authorizations

Normal business hours for prior authorizations and admission authorizations are 8:30 A.M. – 5:00 P.M. Monday through Friday. Routine requests to authorize services can be sent via fax to 234.542.0815 using the Authorization Request Form for Services.

For urgent/expedited requests, call 330.996.8710 or 888.996.8710. After normal business hours and on weekends and holidays routine requests are to be sent via fax to 234.542.0815.

For urgent/expedited requests, nursing home authorizations or inter-facility transfers on weekends/holidays, call 330-414-1653. If a physician determines that care is indicated urgently before authorization can be obtained, then SummaCare will retrospectively review the authorization request on the next business day.

After-hours authorizations for emergency hospital admission may be obtained by calling SummaCare’s 24-hour Nurse Line: 800.379.5001.

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.