Prior authorizations

Getting prior authorization for services

To request prior authorization, you or your provider can call Summit Health Customer Service at 844-827-2355. They can also fax our prior authorization request form 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

Prescription drugs that require prior authorization are listed in our formulary. They will have a “PA” next to them. See our Prior authorization guidelines. You or your provider can,

• Complete our online Coverage determination and exception request (members and providers) form
• Contact Summit Health Pharmacy Customer Service at 844-827-2355. TTY users, dial 711.
• Mail your request by completing this coverage determination and exception request form

Request an exception

If you need a prescription drug that is not in our formulary, you or your provider can request that we cover it.

To request an exception, you or your provider may do one of the following:

• Call Summit Health Pharmacy Customer Service at 844-827-2355. TTY users, dial 711.
• Submit our online Coverage determination and exception request (members and providers) form (coming 01/01/2021)
• Submit a written request by completing this coverage determination and exception request form.
  You may fax it to 855-637-2666, or mail it to:
  Summit Health
  Attn: Summit Health Coverage Determination
  P.O. Box 820070
  Portland, OR 97282

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 out how