Prior authorization codes, criteria, and utilization and/or clinical policies in no way constitutes benefit coverage. Information regarding medications may be found on the pharmacy links located on this website. Please refer to the member's specific Medicare Advantage evidence of coverage (EOC), schedule of benefits, certificate of insurance or summary plan description for benefit coverage.
The Prior Authorization Code “look up”, criteria, Medicare Advantage evidence of coverage (EOC). and utilization and/or clinical policies found on this website are intended to help in interpreting SummaCare standard benefit plans. When determining coverage, the member specific (EOC), schedule of benefits, certificate of insurance or summary plan description documents must be referenced. In the event of a conflict, the member specific benefit document governs.
Before using this webpage or links, please check the member specific benefit plan document and any applicable federal or state mandates. SummaCare follows all Centers for Medicare and Medicaid Services (CMS) and applicable state rules and regulations pertaining to all Medicare Advantage Plans. Unless otherwise stated, all SummaCare policies are appropriate to Medicare Advantage members.
SummaCare reserves the right to modify its Policies as necessary. Policies found on this this website are provided for informational purposes. It does not constitute medical advice or guarantee of payment.
SummaCare may also use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. These tools will support all CMS requirements for Medicare Advantage Plans. SummaCare Clinical Policies are intended to be used in alignment with CMS rules and regulations alongside the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Utilization management (UM) is a process health plans use to evaluate the medical necessity, appropriateness, and efficiency of health care services, procedures and facilities. The process is used to prevent unnecessary or inappropriate care. Some healthcare services require review and authorization by the health plan. SummaCare bases all authorization (concurrent or inpatient, prior authorization, and post service) decisions on reasonable medical evidence and a 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.
Prescription drug benefits incorporate utilization management programs that apply restrictions on certain drugs. These restrictions include, but are not limited to, prior authorization, step therapy and quantity limits.
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 Service.
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.
By Phone:
330.996.8400
or
800-996.8401
By Email:
contactproviderservices@summacare.com
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.