Utilization requests may also be referred to as requests for authorization or pre-authorization. Before using this webpage or links, please check the member specific Evidence of Coverage (EOC) 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. 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 uses medical necessity criteria to help determine the appropriateness of the care or service being requested. The SummaCare Utilization Medical Policy Committee reviews and approves the development of UM criteria. The Utilization Medical Policy Committee consists of primary care and specialty physicians/practitioners who currently provide direct patient care. The SummaCare Utilization Medical Policy Committee reviews and updates medical criteria for UM decision making on an annual basis. SummaCare approved criteria include, but are not limited to:
SummaCare is sensitive to the risks of underutilization of care and service, which include inappropriate or delayed treatment, preventable contraction of disease, extended duration and/or exacerbation of symptoms, undetected progression of disease, misdiagnosis, impaired quality of life, permanent loss of function and preventable death. For this reason, SummaCare distributes annually, an affirmative statement to all of its practitioners, providers, staff and members regarding its incentives to encourage appropriate utilization and discourage underutilization.
SummaCare does not reward physicians/practitioners or other individuals conducting utilization review for issuing denials of coverage. UM decision-making is based only on the existence of coverage and appropriateness of care and service. Financial incentives for UM decision makers do not encourage decisions that result in underutilization (e.g. SummaCare does not use incentives to encourage barriers to care and service). SummaCare does not make decisions regarding hiring, promoting or terminating its practitioners or other individuals conducting utilization review based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.