Prior authorizations and referrals
To help understand what services need prior authorization, Summit Health provides these prior authorization lists.
* Please note that Moda Health performs some administrative functions for Summit Health. Contact us if you need more help.
New! Submit your prior authorization request electronically
Referrals
Summit Health does not require referrals from your patient’s primary care provider in order for your patient to receive specialist services at the in-network rate. Summit Health Medicare Advantage members may see in-network specialists without a referral, though certain procedure or services may require prior authorization.
Prior authorizations for procedures and services
Please refer to these documents to help you determine if your patient needs a prior authorization:
- Procedures and services requiring prior authorization – Please refer to these guidelines to find which procedures will require us to issue an authorization for patients with a Medicare plan (also available in Excel)
- Authorization Form - use this form for submitting a medical authorization request
- Behavioral health authorization form. - use this form for submitting behavioral health authorization requests
Prior authorizations for behavioral health
For help with prior authorizations for behavioral health, see the Behavioral Health support page.
Prior authorizations for pharmacy
For help with prior authorizations for pharmacy, see the Pharmacy support page.
Support by type of procedure or location
Medical Necessity Criteria
Summit Health may develop or adopt medical necessity criteria for certain complex, high cost or highly utilized services on the prior authorization list that do not have an existing National Coverage Determination, Local Coverage Determination, Local Coverage Article, or applicable clinical care guidelines associated with them. These services include, but are not limited to, new technologies (Medical, Behavioral Health, Pharmaceuticals, Devices), new medications and frequently requested services by healthcare providers that require a review for medical necessity.
Medical Necessity Criteria is developed using published scientific evidence and information from relevant governmental regulatory bodies. The criteria is reviewed by the Medical Director, Licensed Psychiatrist, and/or an external specialist review for content and appropriateness.
We have created a complete list of medical necessity criteria that is referenced throughout this section:
- Allergy Testing, Blood
- Blepharoplasty and Brow Ptosis Repair
- Breast Implant Removal
- Breast Reconstruction
- Computer Assisted Navigation
- Endoscopic Procedures for the Treatment of GERD
- Experimental and Investigational Services
- Gender Confirming Surgery
- General DME
- Interspinous Decompression and Interlaminar Stabilization Devices
- Intravitreal Avastin
- Knee Cartilage Transplant
- Mechanical Stretching Devices
- Non-invasive Testing for Liver Fibrosis
- Obstructive Sleep Apnea – Surgical Treatment
- Serum Antibodies for IBD
- Sinus Surgery
- Skin Substitutes
Prior authorization contacts
The Healthcare Services Department can help with prior authorizations on most procedures including the following:
- Inpatient Elective Procedures
- Outpatient Selected Elective Procedures
- Skilled Nursing Facility Long-Term Acute Care
- Inpatient Rehabilitation
- Home Health/Home Infusion
- Hospice – Initial Evaluation and Service
- Durable Medical Equipment (DME)
- Transplants
Need assistance with any of the procedures listed above? Contact the Healthcare Services Department
844-931-1778
Need assistance with Mental Health or Substance Use prior authorizations? Contact the Behavioral Health Department
833-460-0445
Expedited requests
If you need help with getting a request expedited, please call Healthcare Services at 844-931-1778 or fax at 855-637-2666.
An expedited request is completed within 72 hours of receipt. Submitting an expedited request means that you are attesting that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.
Last updated Oct. 1, 2023
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