Prior authorizations

Getting prior authorization for services

To request prior authorization, you or your provider can call Summit Health Customer Service at 844-931-1778. They can also fax our prior authorization request form (English) | prior authorization request form (En Español) to 855-637-2666.

When we say you need to get prior authorization for a service or prescription drug, it means that you need to get pre-approval from us to cover it. Prior authorization is also referred to as organization determination or coverage determination. Prior authorization is required for:

• Ambulatory surgical center (ASC) services
• Cardiac rehabilitation services
• Diabetic services and supplies
• Diagnostic radiology, MRI/CT/CAT/SPECT/PET, nuclear cardiology and radiation therapy
• Durable medical equipment (DME) and related supplies
• Home health
• All home health visits, including skilled nursing, physical therapy, occupational therapy and speech language pathology in the home
• Inpatient hospital care
• Inpatient mental health care
• Inpatient stay: covered services received in a hospital or skilled nursing facility (SNF) during a non-covered inpatient stay
• Medicare Part B prescription drugs, home-infusion drugs and biologicals, see Step Therapy requirements for Medicare outpatient (Part B) medications for more details
• Outpatient rehabilitation services, including physical therapy, occupational therapy and speech language pathology
• Partial hospitalization services for mental health
• Prosthetic devices and related supplies
• Pulmonary rehabilitation services
• Specialty dental services (Medicare-covered)

Getting prior authorization for prescription drugs

To request a prescription drug coverage determination, redetermination, or prior authorization, see our pharmacy coverage determination overview.

How to appeal a decision

You can request a review of a medical or pharmacy decision we have made. You can also file a complaint to Medicare.

Find information on how to file