SummaCare provides high-quality, affordable and comprehensive, community-focused health plans that maximize service with our integrated health system and choice to our providers, members and employers. We are committed to a thorough and effective Quality Management Program that follows the principles of Continuous Quality Improvement to improve the care and services members receive.
Major goals and objectives of the program include:
SummaCare participates in behavioral healthcare clinical studies to look at the coordination of care between medical and behavioral healthcare practitioners in order to improve health outcomes. Learn more about how SummaCare assesses areas of collaboration between medical and behavioral healthcare.
SummaCare reminds and encourages members to get their preventive screenings by mailing annual preventive health letters. For members with chronic conditions such as diabetes and heart disease, care opportunity letters are also sent, which provide important information about screening and care for specific conditions. These letters help identify recommended services for you and your family. The care opportunity letter is only sent to members if we have not received claims by mid-year for the recommended cancer screenings, blood pressure checks and other tests or services. The letters are followed by a reminder phone call later in the year for members with continued care opportunities. SummaCare continues to evaluate and improve our outreach to members and providers to determine additional effective ways to help members get the care they need.
SummaCare’s goal is to offer the highest quality healthcare to our members. This is accomplished, in part, by building a provider network of physician and practitioner professionals who meet SummaCare’s standards.
Through the process of "credentialing," all new physicians and practitioners in the network are reviewed to ensure their professional status is in compliance with our standards. After a physician or practitioner has been credentialed, his or her professional status is re-verified every three years in a process called "recredentialing."
SummaCare also credentials health delivery organizations such as hospitals, skilled nursing facilities and free-standing surgery centers.
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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.