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.

• Prior Authorization List for Services & Equipment
• eviCore Provider’s Hub for High Tech Radiology, Radiation Oncology, Medical Oncology, and Molecular Genomic Laboratory Services (Click "Quick Reference Tool" and follow the instructions below)
  • Click "Type of Health Plan" and select "SummaCare" or "SummaCare/Apex" from the drop down menu
  • Click "Select Solutions" and select the applicable procedure/modality from the drop down menu
  • Scroll to the "Online Forms & Resources" section and click "Select Solution" to select the applicable procedure/modality from the drop down menu to view the information needed to obtain prior authorization for advanced imaging
• Keys to Avoiding Peer to Peer Phone Calls
• Elements of Informed Consent for Genetic Testing (For Provider Use Only, Do Not Fax)
• Prior Authorization Form for Substance Abuse Treatment
• Prior Authorization Request Form for Durable Medical Equipment (DME)
• Prior Authorization Request Form for Drugs Covered Under Medical Benefit
• Prior Authorization Request Form for Services
• Prior Authorization Request Form for Inpatient Skilled Nursing
• Prior Authorization Information: Procedure & Surgery Prior Authorizations 

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.