IRevised May 2016
I. Office Staff Reference Claim Data Element Claims Submission
Directory Electronic Data Interchange (EDI) Submission Member ID
Cards Member’s Rights and Responsibilities Notice of Privacy
Practices Prior Authorization Drug List for Commercial Members
Prior Authorization Drug List for Medicare Members Prior
Authorization Services List (Medicare & Commercial Members)
Prior Authorization Request Form for Drugs Covered Under Medical
Benefit Prior Authorization Request Form for Services Provider
Claim Adjustment Request Provider Support Services SummaCare
Mission Statement Summary of SummaCare Plans SummaCare Website Take
Back Process
II. Quality Management Quality Management Program Summary III.
Medical Management Clinical Management Department Summary
Genetic Testing Request Form Prior Authorization by Fax
Prior Authorization Request Form IV. Pharmacy Management MedImpact
Request Form
TransactRX Vaccine Manager Pharmacy Management Department
Summary
V. Policies & Procedures CLAIMS Claims – Denials
(Medicare)
Claims Submission of Never Events Hospice Interest Payments
(Fully-Insured & Self-Funded Groups)
Interest Payments (Medicare) Medicare Explanation of Benefits
Medicare Member Claim Reimbursement Medicare Remittance
Advice/Notice for Non Contracted Providers Overpayment Recovery
Procedures Overpayment Refund Receipt, Reconciliation and Recording
Process Pended Claims Plan Directed Care Prompt Payment of Claims
(Medicare)
Subrogation CLINICAL MANAGEMENT Access to Board-Certified Physician
Consultant for Utilization Decisions
Care Coordination and Complex Case Management Program Continuity
& Coordination of Care Between Medical & Behavioral Health
Practitioners Coverage of Emergency Services Disease Management
Medicare Pre-Service Organization Determinations Physician Proposal
for Policy/Criteria Modification Transition to Other Care When
Benefits End
Utilization Management COMPLIANCE Antifraud Policy Audit
Coordination
Corporate Confidentiality of Member, Practitioner and Payor
Information Policy Physician/Practitioner Code of Conduct Policy
Prompt Payment of Claims
CREDENTIALING Appeals Process for Physicians/Practitioners Failing
to Meet Recredentialing Criteria Confidentiality of
Physician/Practitioner Information
Credentialing/Recredentialing of Advance Practice Nurses
Credentialing/Recredentialing of Audiologists
Credentialing/Recredentialing of Behavioral Health
Physician/Practitioner Credentialing/Recredentialing of Genetic
Counselors Credentialing/Recredentialing of Occupational
Therapists
Credentialing/Recredentialing of Optometrists
Credentialing/Recredentialing of Physicians, Oral Surgeons,
Podiatrists and Chiropractors
Credentialing/Recredentialing of Speech Pathologists Disruptive
Physician/Practitioner Policy
Office Site Visit and Medical/Treatment Record-Keeping
Physician/Practitioner Appeals Process for Adverse Peer Review and
Determinations
Physician/Practitioner Leave of Absence Physician/Practitioner
Office Site Visit
Physician/Practitioner Performance Improvement Process
Physician/Practitioner Rights and Responsibilities for
Credentialing/Recredentialing
Required Criteria for Participation Types of Individuals
Credentialed/Recredentialed
PHARMACY Coverage for Injectable Drugs Drug Recalls Drug
Utilization Review Information Collection for Pharmacy Benefit
Management Decision Making Lost, Stolen, and Destroyed
Prescriptions
Medicare Part D Compound Drugs Medicare Part D Coverage
Determinations Medicare Part D Coverage Determination Exceptions
Medicare Part D Effect of Failure to Provide Timely Notice to
Medicare Enrollees Medicare Part D Formulary Development Management
Maintenance Communication Medicare Part D Medically Accepted
Indication Medicare Part D Medication Therapy Management Program
Medicare Part D Out-of-Network Pharmacy Access Medicare Part D
Opiate APAP Overutilization Monitoring Medicare Part D OTC Covered
Drugs Medicare Part D Quantity Limits Medicare Part D Request for
Reimbursement Medicare Part D Transition Process Off-label use of
Prescription Drugs Pharmacy Benefit Tier Exceptions Pharmacy Prior
Authorizations Prescription Access during Public Health
Emergencies
Step Therapy Protocols Vacation Overrides QUALITY
MANAGEMENT/APPEALS Assessment of New Technology Clinical Practice
Guidelines Confidentiality of Medical Records –
Physician/Practitioner Sites Continuity and Coordination of Medical
Care
Medical Record Review Documentation Preventative Health
Guidelines
VI. Miscellaneous Acknowledgement of Service (Waiver) Changing
Contact Information Form EDI Provider Registration
Health Education Materials Request Form Informed Consent to
Coordinate of Care Form
Office Staff Reference
CLAIMS DATA ELEMENT (1 of 2)
HCFA Current/Updated National Uniform Claim Committee (NUCC) claim
form A separate claim for each patient (member) Member’s
(patient’s) identification number from their ID card Member’s
(patient’s) name Member’s (patient’s) date of birth and gender
ICD10 diagnosis code(s) Indicate if member (patient) has other
insurance coverage. Date(s) of service (if rental item, it must
include rental date span). DOS must be within member’s
term of coverage. We do not process future dates of service. Place
of service codes and/or modifiers CPT/HCPCS code(s) Charge for each
line of service Claim should not exceed 99 lines of service
Provider Tax ID number NPI # in box 24j and 33b Physician’s
name/signature (unless contracted as a “pay to group”). Correct
total charges If “late or corrected” claim, they should note this
somewhere on the claim. (Prefer box 19) All information on the
entire document MUST BE LEGIBLE
UB A separate claim for each patient (member) Member’s (patient’s)
identification number from their ID card Member’s (patient’s) name
Member’s (patient’s) date of birth and gender Member’s (patient’s)
account number Type of Bill Discharge code Provider’s tax ID number
DRG number (if any – it could be located in 3 to 4 different
locations on claim but must be an
accurate and active DRG number) Date(s) of service Revenue codes
CPT/HCPCS codes and/or modifiers (if any) Charge for each line of
service Correct total charges If the patient is a Medicare member,
the attending physician’s NPI# and name must be in boxes
82 thru 83. All information on the entire document MUST BE LEGIBLE
NPI# in box 56
Claims Data Element
CLAIMS DATA ELEMENT (2 of 2)
ADA (Dental claim form) Claim should be identified as “actual claim
or pre-determination”. A separate claim for each patient (member)
Member’s (patient’s) identification number from their ID card
Member’s (patient’s) name) Member’s (patient’s) date of birth and
gender Member’s (patient’s) account number (if any) Indicate if
member (patient) has other primary dental coverage. Date(s) of
service (if pre-determination, there will not be any DOS). Tooth
number(s) Tooth surface code(s) If prosthesis, date of initial
visit If orthodontics, date of placement of appliance (this date is
vital because in most cases many
dentists bill the patient in monthly installments) Provider should
not submit any x-rays with a claim unless requested by us and/or
for appeals. We
will not be returning any x-rays, they will be recycled. X-rays
cannot be scanned however, some pictures can be scanned.
Dental HCPCS code for each service Unless indicated otherwise, all
dental charges are performed in the office so no location code
is
required on dental claims. Charge for each line of service Correct
total charges Provider tax ID # Provider’s name/signature If “late
or corrected” claim, they should note this somewhere on the claim.
All information on the entire document MUST BE LEGIBLE NPI# in
correct designated box
CLAIMS SUBMISSION (1 of 1)
Claims can be submitted through Electronic Data Interchange (EDI)
SummaCare Payor ID number is 95202. Apex Payor ID number is 34196.
Please send completed paper claim forms and supporting
documentation to: SummaCare P.O. Box 3620 Akron, Ohio 44309-3620
Plan Central Claim Entry Provider offices who do not have the
capability to submit claims via EDI, can submit claims through
SummaCare’s online provider web portal – Plan Central. Claim
submission is available under the “Updates” menu option.
Claims Submission
Provider Support Services For questions about benefits, plan
limits, authorizations, eligibility and claim status please login
to Plan Central. If you are unable to locate the answer to your
question on Plan Central, please call Provider Support Services.
Phone: 330-996-8400 or 800-996-8401 (Hours of business 8:00am –
5:00pm) Fax: 330-996-8490 (please do not fax claims or medical
records) Email: mailto:
[email protected] Plan
Central Registration: Click on the Plan Central button on
www.summacare.com. Health Service Management* Prior Authorization,
Inpatient Concurrent Review, Case Management Phone: 330-996-8710 or
888-996-8710 Fax: Outpatient: 234-542-0815
Inpatient: 234-542-8805 *Providers - Please fax forms to Benefits
Determination Unit. Call Benefits Determination Unit
for emergent prior authorization. *Facilities - Please contact
Benefits Determination Unit with notification of
hospitalization
within 24 hours of admission. Pharmacy To obtain prior
authorization and/or step therapy drug information, please contact
Pharmacy or visit our website at www.summacare.com for the latest
versions of SummaCare’s Drug Formulary and Medicare Part D
Formulary. Phone: 888-783-1780
To obtain prior authorization for prescription drugs, please
contact our Pharmacy Benefit Manager (PBM), MedImpact, at the
number listed below. Please also visit our website at
www.summacare.com for the latest versions of the SummaCare
Commercial Drug Formulary documents and the Medicare Part D
Comprehensive Formulary. Phone: 800-788-2949 Fax: 858-790-7100
Durable Medical Equipment Phone: 330-996-8428 or 866-728-8797 Fax:
330-996-8904 or 234-542-0815 SummaCare Administration Phone:
330-996-8410 or 800-996-8411
PROVIDER CLAIM ADJUSTMENT REQUEST (1 of 1)
Providers may submit their claims electronically through one of our
contracted Trading Partners or they can directly submit their HIPPA
Compliant electronic claim files to us. Our Payor ID’s are
SummaCare 95202 and Apex 34196. Contact EDI Support-
[email protected] for a complete list of Trading Partners or
how to become a direct submitter. Professional Electronic Claims
must include BUT not limited to:
• The Billing Providers NPI and TAX ID Number are required to
submit electronic claims to us. Loop 2010AA
• Multiple claims can be sent on the same electronic file • Member
name • Member’s date of birth and sex • Member’s 11 digit ID Number
• Valid ICD10 diagnosis code
Institutional Electronic Claims must include BUT not limited
to:
• The Billing Providers NPI and TAX ID Number are required to
submit electronic claims to us. Loop 2010AA
• Multiple claims can be sent on the same electronic file • Member
name • Member’s date of birth and sex • Member’s 11 digit ID Number
• Valid ICD10 diagnosis code
Companion Guides and EDI documents can be found on our
website:
• SummaCare – EDI • Apex – EDI
Providers who submit their claims electronically are encouraged to
participate in Electronic Remittance Advice (ERA) and Electronic
Transfer of Funds (EFT).
ERA/EFT documents can be found: • SummaCare – ERA/EFT • Apex –
ERA/EFT
Electronic Data Interchange (EDI) Submission
Electronic Data Interchange (EDI) Submission
________________________________________________________________________________
A – Plan type: This is the type of health insurance plan the member
has. Examples of plan types include Group PPO, Individual PPO, Self
Funded PPO, etc. B – Name of the Plan: This is the name of the
benefit plan the member has. Examples include Plan 5620A, Plan
3700A, Qualified Plan Q1501A, etc. C – Network Name: This is the
name of the provider network. Questions? Please call Provider
Support Services at 800-996-8401 or e-mail
[email protected].
Member ID Cards
Member Rights & Responsibilities
Upon enrollment and at least annually thereafter, SummaCare informs
our members that they have the following rights and
responsibilities. SummaCare employees and all of our contracted
providers are updated on these statements annually as well. These
statements help to ensure that members are treated with fairness
and respect. Equally important, they inform members of their
responsibilities as a health plan member.
These statements promote a mutually respectful relationship between
SummaCare, plan members and their healthcare providers. It is
important that members understand their responsibilities as a
SummaCare member. If they don’t follow these responsibilities, they
may not receive all the services or coverage to which they might
otherwise be entitled.
As a SummaCare member you have the right to:
1. Receive timely and accurate information about SummaCare
including its services, its practitioners and providers, and its
members’ rights and responsibilities;
2. Be treated with fairness, respect and dignity;
3. Be assured your medical records and personal health information
will be handled confidentially and your privacy protected. Please
refer to SummaCare’s NOPP (Notice of Privacy Practices) for a
complete description of your privacy rights;
4. Participate with your healthcare professional in making
decisions about your healthcare;
5. A candid discussion of appropriate or medically/surgically
necessary treatment options for your conditions, regardless of cost
or benefit coverage;
6. Voice complaints or appeals about SummaCare or the care
provided;
7. Provide advance directives that would inform your doctor of your
wishes should you have a terminal illness or lose your ability to
make decisions for yourself;
8. A safe, secure, clean and accessible medical environment;
9. Get information about your coverage and costs as a member of
SummaCare that is easy to understand;
10. Obtain information about SummaCare and our contracted
provider’s financial arrangements and qualifications;
11. To see plan providers, get covered services and get your
prescriptions filled within a reasonable period of time;
12. Make recommendations regarding SummaCare's "Member Rights and
Responsibilities" statement and policy;
MEMBER RIGHTS & RESPONSIBILITIES (1 of 2)
As a SummaCare member you have the responsibility to:
1. Provide to the extent possible, information that SummaCare and
its healthcare professionals need in order to care for you;
2. Understand (to the degree possible) your health problems and
participate in developing and following mutually agreed upon
treatment goals;
3. Follow the guidelines and instructions for care that you have
agreed on with your healthcare professional;
4. Keep medical appointments. If you cannot keep an appointment,
you should notify the healthcare professional’s office;
5. Identify yourself via your membership card, to use the card
appropriately and to assure that other people do not use your
card;
6. Respect SummaCare employees and your healthcare professional and
refrain from using threatening or abusive language or
mannerisms;
7. Act in a way that supports the care given to other patients and
helps the smooth running of your doctor’s office, hospitals and
other offices;
8. Familiarize yourself with your coverage and the rules you must
follow to get care as a SummaCare member;
9. Pay in full any plan premiums, co-payments, co-insurance amounts
or deductibles required by your specific SummaCare benefit
plan;
10. Call SummaCare Customer Service if you have any questions,
suggestions or problems with your care or payment.
How to get more information about your rights and responsibilities:
If you have questions or concerns about your rights and
protections, please call Customer Service at the number listed on
your SummaCare ID card. You can also get free help and information
from the Ohio State Health Insurance Information Program (OSHIP) at
1-800-686-1578 (or TTY 1-614-644-3745). Medicare members may get
additional information by calling 1-800-MEDICARE (1-800-633-4227;
TTY 1-877-486-2048), or by visiting the Medicare website at
www.medicare.gov.
What you can do if you think you have been treated unfairly or your
rights are not being respected: If you think you have been treated
unfairly or your rights have not been respected, you should call
SummaCare Customer Service. Customer Service will ensure that your
issue is addressed, and give you additional information on the
complaint and appeal processes available to you. If you have been
treated unfairly due to your race, color, national origin,
disability, age or religion, please let SummaCare know. You can
also call the Office for Civil Rights in your area.
MEMBER RIGHTS & RESPONSIBILITIES (2 of 2)
SUMMARY
You have the right to: • Get a copy of your health and claims
records • Correct your health and claims records • Request
confidential communication • Ask us to limit the information we
share • Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice • Choose someone to act for you
• File a complaint if you believe your privacy rights have been
violated
Your Rights
Your Choices
You have some choices in the way that we use and share information
as we: • Answer coverage questions from your family and friends •
Provide disaster relief • Market our services
Our Uses and
Disclosures
We may use and share your information as we: • Help manage the
health care treatment you receive • Run our organization • Pay for
your health services • Administer your health plan • Help with
public health and safety issues • Do research • Comply with the law
• Respond to organ and tissue donation requests and work with a
medical
examiner or funeral director • Address workers’ compensation, law
enforcement, and other government requests • Respond to lawsuits
and legal actions
Privacy Officer: Michael Frye Phone: 330-996-8912 email:
[email protected]
SummaCare 10 North Main Street Akron, OH 44308
www.summacare.com
Get a copy of health and claims records
• You can ask to see or get a copy of your health and claims
records and other health information we have about you. Ask us how
to do this.
• We will provide a copy or a summary of your health and claims
records, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.
Ask us to correct health and claims records
• You can ask us to correct your health and claims records if you
think they are incorrect or incomplete. Ask us how to do
this.
• We may say “no” to your request, but we’ll tell you why in
writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example,
home or office phone) or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if
you tell us you would be in danger if we do not.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no”
if it would affect your care.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared
your health information for six years prior to the date you ask,
who we shared it with, and why.
• We will include all the disclosures except for those about
treatment, payment, and health care operations, and certain other
disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based
fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if
you have agreed to receive the notice electronically. We will
provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone
is your legal guardian, that person can exercise your rights and
make choices about your health information.
• We will make sure the person has this authority and can act for
you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by
contacting us. • You can file a complaint with the U.S. Department
of Health and Human Services
Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Rights
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities
to help you.
In these cases, you have both the right and choice to tell us
to:
• Share information with your family, close friends, or others
involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you
are unconscious, we may go ahead and share your information if we
believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat to
health or safety.
In these cases we never share your information unless you give us
written permission:
• Marketing purposes • Sale of your information
Help manage the healthcare treatment you receive
• We can use your health information and share it with
professionals who are treating you.
Example: A doctor sends us information about your diagnosis and
treatment plan so we can arrange additional services.
Run our organization • We can use and disclose your information to
run our organization and contact you when necessary.
• We are not allowed to use genetic information to decide whether
we will give you coverage and the price of that coverage. This does
not apply to long term care plans.
Example: We use health information about you to develop better
services for you.
Pay for your health services We can use and disclose your health
information as we pay for your health services.
Example: We share information about you with your dental plan to
coordinate payment for your dental work.
Administer your plan We may disclose your health information to
your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan,
and we provide your company with certain statistics to explain the
premiums we charge.
Your Choices
For certain health information, you can tell us your choices about
what we share. If you have a clear preference for how we share your
information in the situations described below, talk to us. Tell us
what you want us to do, and we will follow your instructions.
Our Uses and
Disclosures How do we typically use or share your health
information? We typically use or share your health information in
the following ways.
How else can we use or share your health information? We are
allowed or required to share your information in other ways –
usually in ways that contribute to the public good, such as public
health and research. We have to meet many conditions in the law
before we can share your information for these purposes. For more
information see: www.hhs.gov/ocr/
privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues We can share health
information about you for certain situations such as:
• Preventing disease • Helping with product recalls • Reporting
adverse reactions to medications • Reporting suspected abuse,
neglect, or domestic
violence • Preventing or reducing a serious threat to
anyone’s
health or safety
Do research We can use or share your information for health
research.
Comply with the law We will share information about you if state or
federal laws require it, including with the Department of Health
and Human Services if it wants to see that we’re complying with
federal privacy law.
Respond to organ and tissue donation requests and work with a
medical examiner or funeral director
• We can share health information about you with organ procurement
organizations.
• We can share health information with a coroner, medical examiner,
or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other
government requests We can use or share health information about
you:
• For workers’ compensation claims • For law enforcement purposes
or with a law
enforcement official • With health oversight agencies for
activities authorized
by law • For special government functions such as military,
national security, and presidential protective services
Respond to lawsuits and legal actions We can share health
information about you in response to a court or administrative
order, or in response to a subpoena.
Our Responsibilities • We are required by law to maintain the
privacy and
security of your protected health information. • We will let you
know promptly if a breach occurs that
may have compromised the privacy or security of your
information.
• We must follow the duties and privacy practices described in this
notice and give you a copy of it.
• We will not use or share your information other than as described
here unless you tell us we can in writing. If you tell us we can,
you may change your mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/
understanding/consumers/noticepp.html.
Changes to the Terms of this Notice We can change the terms of this
notice, and the changes will apply to all information we have about
you. The new notice will be available upon request, on our web
site, and we will mail a copy to you.
Effective date: September 23, 2013
(CONTINUED) 1
Medical Prior Authorization List (For Drugs Administered in an
Office, Home or Outpatient Setting)
Effective September 7, 2015
THIS LIST APPLIES TO ALL COMMERCIAL FULLY-INSURED MEMBERS
Certain drugs require prior authorization in order to be covered
under your health plan. Prior authorization review is the process
of determining the medical necessity of a proposed procedure,
surgery or treatment (including prescribed drug intervention)
relative to approved criteria. Prior authorization is required to
ensure that the drug is medically necessary and you will receive
the benefits to which you are entitled.
Requests for prior authorization must be received before the
services or drugs are provided/administered. Failure of a network
provider to contact SummaCare for required authorization of items
covered under your benefit plan will relieve the health plan and
you from any financial responsibility for the service if those
services are rendered before notifying the plan.
NOTE: Your in-network providers are responsible for obtaining
authorization 48 hours prior to administering these prescription
drugs. If you use a provider that is not in your network, it is
your responsibility to obtain any required prior
authorization.
For Providers: Network providers are responsible for obtaining
authorization at least 48 hours before rendering these prescription
drugs.
How to request prior authorization for drugs covered under the
medical benefit: o Fax submission of requests for prior
authorization should be used for nonurgent requests. o Routine
requests: Fax 234-231-7082 o Urgent requests: Call 330-996-8710 or
888-996-8710
SummaCare provides coverage under the medical benefit for many
drugs that are administered in an office, home or outpatient
setting. We require certain drugs to receive prior authorization
before being administered. The following drugs may require prior
authorization:
ABILIFY MAINTENA (aripiprazole) ACTEMRA (tocilizumab) ACTHAR GEL
(corticotropin) ADAGEN (pegademase) ALDURAZYME (laronidase)
ALPHANATE (antihemophilic factor) ALPROLIX (factor product) ARALAST
(alpha proteinase inhibitor) ARCALYST (rilonacept) ARZERRA
(ofatumumab) AVONEX (interferon beta-1a) BEBULIN/BEBULIN VH (factor
product) BELEODAQ (belinostat) BENEFIX (factor product) BENLYSTA
(belimumab)
BIVIGAM (immune globulin) BLINCYTO (blinatumomab) BONIVA IV
(ibandronate) BOTOX (onabotulinumtoxin A) CARIMUNE (immune
globulin) CAYSTON (aztreonam) inhalation CEREZYME ( imiglucerase)
CIMZIA (certolizumab pegol) CINRYZE (C1 inhibitor) CORIFACT (factor
product) CYRAMZA (ramucirumab) DYSPORT (abobotulinumtoxin A)
ELAPRASE (idursulfase) ELELYSO (taliglucerase---alfa) ENTYVIO
(vedolizumab)
(CONTINUED) 2
PROLIA (denosumab) PROVENGE (sipuleucel-T) QUTENZA (capsaicin 8%
patch) RECLAST (zoledronic acid) RELISTOR (methylnaltrexone
bromide) REMICADE (infliximab) RISPERDAL CONSTA (risperidone LA)
RITUXAN (rituximab) RIXUBIS (factor product) SIGNAFOR LAR
(pasireotide pamoate) SIMPONI ARIA (golimumab) SOLIRIS (eculizumab)
STELARA (ustekinumab) SUPPRELIN LA (histralin) implant SYLVANT
(acyclovir) SYNAGIS (palivizumab) SYNRIBO (omacetaxine
mepesuccinate) TEFLARO (ceftaroline fosamil) TEMODAR (temozolomide)
TESTOPEL (testosterone pellets) TRETTEN (factor product) TYSABRI
(natalizumab) TYVASO (treprostinil) VECTIBIX (panitumumab) VENTAVIS
(iloprost) VORAXAZE (glucarpidase) VPRIV (velaglucerase) XEOMIN
(incobotulinumtoxin A) XGEVA (denosumab) XIAFLEX (collagenase)
XOFIGO (radium Ra 223 dichloride) XOLAIR (omalizumab) XYNTHA
(antihemophilic factor) YERVOY (ipilimumab) ZALTRAP
(ziv-afilbercept) ZEMAIRA (alpha proteinase inhibitor)
IMPORTANT INFORMATION: 1. This document is not intended to
interfere with urgently needed care. Urgent care is any request for
medical care or
treatment in which the time periods for SummaCare to make nonurgent
care determinations (within 14 days) could result in the following
circumstances:
o Could seriously jeopardize the life or health of the member or
the member’s ability to regain maximum function, based on a prudent
layperson’s judgment; or
o In the opinion of a practitioner with knowledge of the member’s
medical condition, would subject the member to severe pain that
cannot be adequately managed without the care or treatment that is
the subject of the request.
If in the judgment of the rendering provider the care is of an
emergency or urgent nature, the plan will review for medical
necessity after the care has begun.
2. All services, even if authorized, are subject to your benefit
plan contract coverage and exclusions, eligibility and network
design. Approvals are not a guarantee of coverage, as your benefit
plan contract may retroactively terminate at a future date.
3. Services not listed on this document may not be covered because
they are listed as exclusions on your plan contract. Your benefit
plan contract exclusions and current status of eligibility may be
verified online at www.summacare.com. Call the customer service
number on your member identification card to inquire about
eligibility and coverage.
4. Providers may visit Plan Central at
https://SummaCare.myplancentral.com to view eligibility and
benefits or register for a user account. For additional questions,
please email
[email protected].
3
To find the most current list of services, surgeries, durable
medical equipment or drugs covered under your medical benefit
requiring prior authorization, please visit www.summacare.com or
call the customer service number located on your member
identification card. If you are unsure as to what requires prior
authorization, please call customer service.
(CONTINUED) 1
Medical Prior Authorization List (For Drugs Administered in an
Office, Home or Outpatient Setting)
Effective September 7, 2015 - PROVIDER COPY THIS LIST APPLIES TO
ALL MEDICARE MEMBERS
Certain drugs require prior authorization in order to be covered
under your health plan. Prior authorization review is the process
of determining the medical necessity of a proposed procedure,
surgery or treatment (including prescribed drug intervention)
relative to approved criteria. Prior authorization is required to
ensure that the drug is medically necessary and you will receive
the benefits to which you are entitled.
Requests for prior authorization must be received before the
services or drugs are provided/administered. Failure of a network
provider to contact SummaCare for required authorization of items
covered under your benefit plan will relieve the health plan and
you from any financial responsibility for the service if those
services are rendered before notifying the plan.
NOTE: Network providers are responsible for obtaining authorization
at least 48 hours before administering these prescription drugs. If
the provider is not in the plan network, it is the member’s
responsibility to verify that prior authorization has been
obtained.
How to request prior authorization for drugs covered under the
medical benefit:
o Fax submission of requests for prior authorization should be used
for nonurgent requests. o Routine requests: Fax 234-231-7082 o
Urgent requests: Call 330-996-8710 or 888-996-8710
SummaCare provides coverage under the medical benefit for many
drugs that are administered in an office, home or outpatient
setting. We require certain drugs to receive prior authorization
before being administered. The following drugs may require prior
authorization:
ACTEMRA (tocilizumab) ACTHAR GEL (corticotropin) ALPHANATE
(antihemophilic factor) ALPROLIX (factor product) ARZERRA
(ofatumumab) AVONEX (interferon beta-1a) BEBULIN/BEBULIN VH (factor
product) BELEODAQ (belinostat) BENEFIX (factor product) BENLYSTA
(belimumab) BIVIGAM (immune globulin) BLINCYTO (blinatumomab)
BONIVA IV (ibandronate) BOTOX (onabotulinumtoxin A) CARIMUNE
(immune globulin) CIMZIA (certolizumab pegol) CINRYZE (C1
inhibitor) CORIFACT (factor product)
CYRAMZA (ramucirumab) DYSPORT (abobotulinumtoxin A) ELELYSO
(taliglucerase---alfa) ENTYVIO (vedolizumab) ERBITUX (cetuximab)
FLEBOGAMMA (immune globulin) FLOLAN (epoprostenol) GAMASTAN (immune
globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin)
GAMMAPLEX (immune globulin) GAMUNEX-C (immune globulin) GAZYVA
(obinutuzumab) GLASSIA (proteinase inhibitor) HALAVEN (eribulin
mesylate) HEMOFIL M (antihemophilic factor) HERCEPTIN (trastuzumab)
HIZENTRA (immune globulin) HYQVIA (immune globulin)
(CONTINUED) 2
PROVIDER COPY
XIAFLEX (collagenase) XOFIGO (radium Ra 223 dichloride) XOLAIR
(omalizumab) XYNTHA (antihemophilic factor) YERVOY (ipilimumab)
ZALTRAP (ziv-afilbercept)
PROVIDER COPY
IMPORTANT INFORMATION: 1. This document is not intended to
interfere with urgently needed care. Urgent care is any request for
medical care or
treatment in which the time periods for SummaCare to make nonurgent
care determinations (within 14 days) could result in the following
circumstances:
o Could seriously jeopardize the life or health of the member or
the member’s ability to regain maximum function, based on a prudent
layperson’s judgment; or
o In the opinion of a practitioner with knowledge of the member’s
medical condition, would subject the member to severe pain that
cannot be adequately managed without the care or treatment that is
the subject of the request.
If in the judgment of the rendering provider the care is of an
emergency or urgent nature, the plan will review for medical
necessity after the care has begun.
2. All services, even if authorized, are subject to your benefit
plan contract coverage and exclusions, eligibility and
network design. Approvals are not a guarantee of coverage, as your
benefit plan contract may retroactively terminate at a future
date.
3. Services not listed on this document may not be covered because
they are listed as exclusions on your plan contract.
Your benefit plan contract exclusions and current status of
eligibility may be verified online at www.summacare.com. Call the
customer service number on your member identification card to
inquire about eligibility and coverage.
4. Providers may visit Plan Central at
https://SummaCare.myplancentral.com to view eligibility and
benefits or register
for a user account. For additional questions, please email
[email protected].
3
To find the most current list of services, surgeries, durable
medical equipment or drugs covered under your medical benefit
requiring prior authorization, please visit www.summacare.com or
call the customer service number located on your member
identification card. If you are unsure as to what requires prior
authorization, please call customer service.
Effective September 7, 2015 - PROVIDER COPY
THIS LIST APPLIES TO ALL COMMERCIAL FULLY-INSURED & MEDICARE
MEMBERS
Certain services require prior authorization in order to be covered
under the member’s health plan. Prior authorization review is the
process of determining the medical necessity of a proposed
procedure, surgery or treatment (including prescribed drug
intervention) relative to approved criteria. Prior authorization is
required to ensure that the service is medically necessary and that
the member will receive the benefits to which the member is
entitled.
Requests for prior authorization must be received before the
services are provided. Failure of a network provider to contact the
health plan for required authorization of items covered under the
member’s plan will relieve the health plan and the member from any
financial responsibility for the service, if those services are
rendered before notifying the plan.
NOTE: Network providers are responsible for obtaining authorization
at least 48 hours before provision of services.
How to request prior authorization for services:
Medical Prior Authorization List (For Services and Equipment)
SERVICES SummaCare provides coverage for medically-necessary
healthcare services. SummaCare requires prior authorization before
the provision of select services. The list of services below may
change. The most up-to-date listing of services needing prior
authorization is maintained at www.summacare.com.
The following services require prior authorization: • Referrals to
a surgeon for back pain • Ambulance
Transport by fixed-wing plane Elective (nonemergency)
transportation by ground
ambulance • Applied behavioral analysis (ABA) • CardioMEMS system •
Cochlear device and/or implantation
• Cosmetic or potentially cosmetic surgery or procedures • Dental
care that is non-routine and is needed for the
purpose of treating illness or injury • Experimental medical and
surgical procedures and new
technology • Genetic testing • Hyperbaric oxygen therapy •
Infertility diagnostic and treatment services • Infusions of
ketamine, lidocaine for pain • Inpatient confinements
Acute care hospital Behavioral health hospital Long-term acute care
hospital Rehabilitation facility Residential treatment center
Skilled nursing facility, sub-acute or
transitional care facility
Type of Service 24/7 Online Requests* Routine Requests Urgent
Requests Ambulance N/A 330-996-8791 or
866-996-8791 330-996-8791 or 866-996-8791
Inpatient N/A Fax 234-542-0811 330-996-8710 or 888-996-8710
All other requests N/A Fax 234-542-0815 330-996-8710 or
888-996-8710
*Fax submission of requests for prior authorization should be used
for nonurgent requests.
(CONTINUED) 1
Computed Tomography (except CT of the sinus) Gastrointestinal
imaging through capsule
endoscopy Magnetic resonance imaging (MRI) Magnetic resonance
angiography (MRA) Magnetic resonance spectroscopy (MRS) Nuclear
medicine scans Positron Emission Tomography (PET) Single-Photon
Emission Computed Tomography
(SPECT) • Transplant services
transplants
OUTPATIENT SURGERIES SummaCare provides coverage for medically
necessary outpatient surgeries. SummaCare requires certain
outpatient surgeries to receive prior authorization before the
provision of services. The list of surgeries below may change. The
most up-to-date listing of outpatient surgeries needing prior
authorization is maintained at www.summacare.com.
The following outpatient surgeries require prior
authorization:
• Bariatric surgery • Implanted cardioverter defibrillator •
Orthognathic surgery procedures, bone grafts,
osteotomies and surgical management of the temporomandibular
joint
• Spinal/back surgery • Spinal cord stimulator • Stereotactic
radiosurgery (e.g. Cyberknife, Gammaknife) •
Uvulopalatopharyngoplasty
DURABLE MEDICAL EQUIPMENT & PROSTHETICS SummaCare provides
coverage for medically necessary durable medical equipment.
SummaCare requires certain durable medical equipment receive prior
authorization before the provision of services. The list of items
below may change. The most up-to-date list of durable medical
equipment needing prior authorization is maintained at
www.summacare.com.
The following durable medical equipment requires prior
authorization:
• Bone growth stimulator • Cardioverter defibrillator (wearable),
including AED
garment • Electric transport devices (e.g. wheelchairs, scooters) •
Home oxygen therapy • Insulin pump, ambulatory • Negative pressure
wound therapy • Noninvasive airway assistive devices and
accessories • Orthopedic or therapeutic shoes (Medicare Only) •
Orthotic devices (Medicare Only) • Orthotic shoe inserts (Medicare
Only) • Pneumatic compression device • Prosthetics/prosthetic
devices • Scooter, electric or motorized • Speech generating device
• Wound products (e.g. platelet gels, human allograft
products, matrix products, skin replacement products) • Ventilator
(portable/home)
(CONTINUED) 2
PROVIDER COPY
IMPORTANT INFORMATION 1. This document is not intended to interfere
with urgently needed care. Urgent care is any request for medical
care or
treatment in which the time periods for SummaCare to make nonurgent
care determinations (within 14 days) could result in the following
circumstances: • Could seriously jeopardize the life or health of
the member or the member’s ability to regain maximum function,
based on a prudent layperson’s judgment; or • In the opinion of a
practitioner with knowledge of the member’s medical condition,
would subject the member to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the
request. If in the judgment of the rendering provider the care is
of an emergency or urgent nature, the plan will review for medical
necessity after the care has begun.
2. All services, even if authorized, are subject to the member’s
benefit plan contract coverage and exclusions, eligibility and
network design. Approvals are not a guarantee of coverage, as the
member’s benefit plan contract may retroactively terminate at a
future date.
3. Services listed on this document may not be covered because they
are listed as exclusions on the member’s plan contract. Benefit
plan contract exclusions and current status of eligibility may be
verified online at www.summacare.com.
4. Providers may visit Plan Central at
https://SummaCare.myplancentral.com to view eligibility and
benefits or register for a user account. For additional questions,
please email
[email protected].
3
To find the most current list of services, surgeries, durable
medical equipment or drugs requiring prior authorization, please
visit www.summacare.com.
PROVIDER COPY
PRIOR AUTHORIZATION REQUEST FOR DRUGS COVERED UNDER THE MEDICAL
BENEFIT
(ie. Drugs given via IM or IV administered in an office, home, or
outpatient setting) Please fax to 234-231-7082
*For urgent requests only, please call 330-996-8710
DATE
MEMBER ID # MEMBER DOB
PHONE # FAX #
NEW REQUEST REAUTHORIZATION REQUEST
PLACE OF SERVICE/FACILITY OUTPT PROVIDER OFFICE
IS THE PROVIDER BUYING AND BILLING FOR THE MEDICATION? YES NO
CLINICAL INFORMATION - PERTINENT TO DRUG BEING REQUESTED
(ATTACH
COPIES OF PERTINENT CLINICALS)
Include symptoms/findings, labs, tests, imaging, and conservative
treatment, if any.
CONFIDENTIALITY NOTICE: This communication and any attachments may
contain confidential and privileged information for the use of the
designated recipients. If you are not the intended recipient, you
are hereby notified that you have received this communication in
error and any review, disclosure, distribution, or copying of it or
its contents is prohibited. If you have received this communication
in error, please notify us immediately by telephone and return the
original message to us at 10 N. Main St., Akron, OH 44308 via the
USPS. If this was an email received in error, please notify the
sender and delete it.
AUTHORIZATION #
INPATIENT 234-542-0811 RADIOLOGY 800-540-2406 All Other
234-542-0815 *For urgent requests only, please call 330 996-8710 or
888 996-8710
DATE MEMBER NAME LAST FIRST MI
MEMBER ID # MEMBER DOB ___________
PROCEDURE ORDERED DATE OF SERVICE DIAGNOSIS
CPT CODE(S) ICD-9 DX CODE
ELECTIVE ADMISSION GENETIC TESTING Patient Counseling
Completed
OUTPATIENT SURGERY Basic Elements of Informed Consent for Genetic
Testing IMAGING Basic Elements of Informed Consent for Cancer
Susceptibility OUT OF NETWORK REFERRAL By signing, I certify that
the member above has been NEW TECHNOLOGY counseled according to
guidelines checked above.
OTHER Physician’s Signature _______________________________
CLINICAL INFORMATION - PERTINENT TO PROVIDER SERVICE (ATTACH COPIES
OF PERTINENT
CLINICALS)
_________________________________________________________________________________________________
CONFIDENTIALITY NOTICE: This communication and any attachments may
contain confidential and privileged information for the use of the
designated recipients. If you are not the intended recipient, you
are hereby notified that you have received this communication in
error and any review, disclosure, distribution, or copying of it or
its contents is prohibited. If you have received this communication
in error, please notify us immediately by telephone and return the
original message to us at 10 N. Main St., Akron, OH 44308 via the
USPS. If this was an email received in error, please notify the
sender and delete it.
AUTHORIZATION # CONTACT
Please complete each section of this form. Print clearly, using
black or blue ink only. Incomplete or illegible information may
delay your response or cause your request to be returned.
Date:________________
Are you submitting a corrected claim? Please submit your corrected
claim electronically with the appropriate indicator. If you are
submitting a paper claim, please write ‘corrected claim’ in box 19.
The adjustment request form should not be used for corrected
claims. Fee/Contract Pricing Dispute Itemized Bill Enclosed (if
requested by the plan) Unlisted Procedure Code/Modifier 22
Denial
Are you submitting the Primary EOP? Please indicate the claim
number below and mail this adjustment request form with the primary
EOP. Overpayment Correspondence (Check Enclosed) Refund checks
should be submitted with a copy of the overpayment letter in order
to process the refund timely and accurately. Timely Filing Proof of
timely filing must be submitted in order for the adjustment request
to be considered.
Not a Duplicate Charge (Denied CB) My claim denied as a duplicate,
but it is not a duplicate. Provide explanation in the space
provided below. Medical Necessity Dispute (EX 87,88,89) Additional
clinical information must be submitted)
Overpayment Correspondence (No Check Enclosed) You are submitting
an explanation as to why you are not submitting a refund that has
been requested OR you are requesting that we request a refund on a
duplicate or incorrect payment. Medical Records Enclosed (if
requested by plan) Please do not submit medical records unless the
plan requests them. This will save you the time of submitting
medical records that are not necessary to consider your
claim.
Requester/Contact Name: Email Address:
Provider Name: Fax Number:
Provider Claim Adjustment Request
Type of Request
Send completed form to: SummaCare, Attn: Mailroom, P.O. Box 3620,
Akron, OH 44309-3620
PROVIDER CLAIM ADJUSTMENT REQUEST (2 of 2)
If the claim does not fall into one of the above outlined
categories, please contact the Provider Support Service Unit at
330-996-8400 or 800-996-8401.
1. If there are multiple claims that fall under the same “Type of
Request”, please submit one form with an attached spreadsheet
containing all of the requested information for each individual
claim.
2. Instructions for submitting the completed form are found at the
bottom of the form.
3. This form can be copied for future use. This form is also
available at: www.summacare.com on
the Provider Homepage.
Provider Support Services For questions about benefits, plan
limits, authorizations, eligibility, claim status, and all other
general inquiries; please visit our website at www.summacare.com to
login to Plan Central. Phone: 330-996-8400 or 800-996-8401 Email:
mailto:
[email protected]
Click Before You Call In order to improve efficiencies and
eliminate lengthy hold times, SummaCare is directing providers who
call for basic plan information to use Plan Central – our secure
provider web portal. Plan Central is the provider’s source for
day-to-day operations for efficient, real time answers to basic
plan inquiries. Effective December 15, 2013, providers who call
Provider Support Services for basic plan information will be
advised to use Plan Central. This new process eliminates calls for
basic inquiries, which allows Provider Service Representatives to
be available to answer complex calls which require our assistance.
If your office uses a billing company, please make sure your
billing company is also aware of this new process and obtains
access to the site so the workflow in your office is not
interrupted.
If you do not have a username and password, please visit
www.SummaCare.com, click the Provider tab then Resources and Self
Services and select Plan Central to register for a user account. To
Help Us Serve You Better When contacting Provider Support Services,
please select the appropriate prompt and have detailed information
available as outlined below: Eligibility, Benefits and
Authorizations Physician/Provider Tax ID Number Name of the person
calling Date of service (if applicable) Member name and member I.D.
number Name of the procedure/CPT code Setting where service
performed (Inpatient/outpatient/office)
Claims and All Other General Inquiries Physician/Provider Tax ID
Number Name of the person calling Member name and member I.D.
number Name of the physician/provider of service Total charges
billed Date of service (if applicable) Contracting questions
Provider Support Services
SUMMACARE’S VISION, MISSION AND VALUES (1 of 1)
Our Vision: Providing access to the highest quality of service,
products, and education for our internal and external customers in
the communities that we serve. Our Mission: Providing our customers
with comprehensive, community-focused health care choices priced to
reflect quality, value, and service. Our Value: Our values provide
the framework for each of us to support the mission in our
day-to-day work by emphasizing the beliefs and attitudes, which
govern the operations of the system. They are an affirmation of
what is most important for the success of our organization and
reflect a belief that success is a personal standard compelling us
to strive to reach our highest potential as individuals in service
to our community. We believe in the highest standards of personal
and organizational integrity. Honesty and fairness
are expected from all of us. We believe in preserving a quality,
caring organizational environment. Each of us will take
responsibility for continuously improving the quality of service he
or she provides. We believe in excellence in leadership throughout
the organization. All who lead must also
facilitate the efforts of our employees in best serving our
customers, as well as service in a mentoring and educating role to
support all employees in achieving their full potential.
We believe in valuing one another. Each of us will value the
knowledge, experience and ability of
other employees and the contribution that each makes to Summa. We
believe that we all deserve respect and fair treatment. Each of us
will support these
fundamental premises by being an example of this positive behavior.
We believe in open communication. Each of us will continually
strive to remove communication
barriers. Group participation is encouraged in the resolution of
issues. We believe in teamwork. We value the participative process
and consensus building. It is through
cooperation that our greatest successes will be derived. We believe
in community service. We encourage all of our employees to be good
community
citizens and seek opportunities of service to others. We believe in
individuality. We value diversity in experience and perspectives at
all levels of our
work force. Differing points of view will be sought and
respected.
SummaCare’s Vision, Mission and Values
SUMMARY OF SUMMACARE PLANS (1 of 1)
Fully-Insured SummaCare PPO – a self-referral system. This plan is
not PCP driven and members may choose to stay in-network with
higher levels of coverage or go out-of-network incurring greater
out-of-pocket expenses in the form of deductibles and/or
coinsurance amounts. Medicare Medicare Advantage Plans – Corporate
(employer) and individual plans are available. Service area
includes Summit, Stark, Portage, Medina, Cuyahoga, Wayne, Lake,
Ashtabula, Trumbull, Mahoning, Columbiana, Tuscarawas, Geauga,
Holmes, Lorain, Ashland, Richland, Morrow, Huron, Erie, Crawford,
Marion, Wyandot, Seneca, Sandusky, Ottawa, Lucas, Wood, Hancock,
Hardin, Auglaize, Allen, Putnam, Henry, Fulton, Williams, Defiance,
Paulding, Van wert, Mercer and Carroll Counties. Supplemental
Solutions – a comprehensive health plan option for individuals and
families. This product is a PPO plan. Members can choose to stay
in-network with higher levels of coverage or go out-of- network
incurring greater out-of-pocket expenses in the form of deductibles
and/or coinsurance. Self-Funded A wide variety of self-insured
plans are offered through SummaCare’s third-party administrator,
Apex Benefits Services. The type of plan (i.e., PPO, EPO, etc.) is
listed on the member’s ID card. For questions, please call Provider
Support Services at (800) 996-8401 or email
mailto:
[email protected]
Summary of SummaCare Plans (Fully-Insured and Self-Funded)
SummaCare Web-based Services SummaCare offers its members and
providers a great deal of information that can be accessed through
our website at www.summacare.com.
On the SummaCare website, the Providers tab along the menu bar
allows access to the web-based services and programs designed for
use by SummaCare’s providers.
When clicking the Provider Tab from the main menu, you will see the
following:
Resourced & Self Services - Quickly find the tools you need!
Access SummaCare’s online provider manual, forms, prior
authorization lists, patient eligibility (Plan Central) and
more.
Become a Network Provider- Learn more about becoming part of
SummaCare’s network of quality providers and print or submit an
online application.
News & Updates - Find the latest provider updates, seminar
information and archived Provider Press newsletters.
Clinical Management - SummaCare has several disease management
programs, case management services and wellness services to help
our members live healthier, happier lives. Learn how to refer your
patients!
Quality Management - The objectives of our quality management
program include promoting and building quality into the structure
and processes of our organization and monitoring and working to
improve outcomes.
SummaCare Plans & Benefits - Learn about SummaCare’s full line
of health insurance products.
Find a Doctor or Hospital
Compliance Training - All providers who contract with SummaCare
Medicare Advantage services are expected to abide by CMS rules and
regulations. Annual Compliance training is provided on
Summacare.com
Provider Support Services – Provides information on when and how to
contact Provider Services for assistance or plan education.
SummaCare Website
TAKE BACK PROCESS ON OVERPAYMENT (1 of 1)
If a provider office prefers take backs be done on all overpaid
claims, a signed letter on office letterhead agreeing to take backs
across the board should be submitted to SummaCare. This would apply
to all overpayments pending and in the future. Providers are not
notified in advance of the take back. A refund request letter will
be sent in the event the overpayment is not recouped within 90
days. Please send the above mentioned letter of agreement to:
SummaCare Insurance Company Attention: Recovery 10 N. Main St.
Akron OH 44308 Any questions regarding the take back process should
be directed to Provider Support Services at 330- 996-8400 or
800-996-8401. Providers may also email questions to
[email protected] .
Take Back Process on Overpayment
QUALITY MANAGEMENT PROGRAM SUMMARY (1 of 1)
SummaCare’s mission is to work with providers, members and
employers to provide a comprehensive, community-focused health plan
that maximizes service and choice while minimizing cost. The
SummaCare Quality Management Program supports our mission by
assessing performance, identifying opportunities for improvement
and facilitating change to improve the quality and safety of care
and service provided and to promote member management of their
health. Review activities encompass the following: Quality and
utilization of all medical and behavioral healthcare services in
all care settings provided to
all enrolled demographic groups, including inpatient and outpatient
services provided by physicians, practitioners, hospitals and other
providers
Continuity and coordination of care, under-utilization and
over-utilization Review of health plan clinical and business
operations including Utilization Management, Quality
Management, Risk Management, Customer and Provider Services,
Credentialing, Claims Processing, Eligibility Processing, Appeals,
Sales, Human Resources, Training, etc.
Member and provider satisfaction information Trending and
evaluation of complaints, grievances and appeals. Oversight of the
quality of non-clinical aspects of service such as availability and
access, claims
timeliness, call answer timeliness, call abandonment, etc. Special
clinical studies for the Medicare population as specified and
required by the Centers for
Medicare and Medicaid Services Ongoing assessment of the scope,
content and performance of the Quality Management Program to
ensure compliance with all regulatory and NCQA accrediting
standards o This includes annual HEDIS data collection, analysis
and improvement activities o The annual Quality Management Program
Description and Quality Management Program
Evaluation documents are available for review on the SummaCare
website www.summacare.com
Oversight of the Quality Management Program is provided by the
SummaCare Board of Directors and is directly accountable to the
SummaCare Executive Quality/Compliance Council (EQCC). The
President and Chief Medical Officer sit on the Board. Other
committees support the work of the Quality Program and report to
the EQCC. Please see the Quality Management Program Description on
www.summacare.com. You are encouraged to direct questions or
concerns about SummaCare’s quality management program to the
Director of Quality Management at 330-996-8421.
Resources: Quality Management Program Description
Quality Management Program Summary
Responsibility:
• Authorization and Medical Necessity Review • Enhanced Care
Management Programs
o Chronic Disease Self-Management Programs o “Bridge-to-Home”
Transitional Care o “Bridge Units” for skilled nursing stays o
“SummaCare Physicians House Calls Program” o “Comprehensive At Home
Care Program” for end of life o “Intense Case Management”
• Case Management/Care Coordination • Complex Case Management
Goals:
• Member support and education for effective healthcare self
management • Provider support and assistance with helping members
find needed and coordinated, appropriate
care • Health plan benefit management that maximizes the members’
benefits for receiving quality care
in clinically appropriate settings Achievements:
• Updated disease management programs for diabetes, heart failure,
asthma, chronic kidney disease, and depression
• Enhanced Care Management programs targeted at frail elders with
multiple co-morbidities • Case management programs targeted at
catastrophic illness and high-risk members
Clinical Management Department Summary
Please fax to 330-996-8605 / 330-996-8904 or call 330-996-8710 /
888-996-8710 for urgent requests
Member Last Name:
Member First Name:
Requesting Physician First & Last Name:
Practice/Group Name:
Physician Contact Name:
Facility/Place of Service:
Patient Counseling Completed: Basic Elements of Informed Consent
for Genetic Testing Basic Elements of Informed Consent for Cancer
Susceptibility
By signing this form, I certify that the member above has been
counseled according to the guidelines checked above.
______________________________________________________ Physician
Name (print) ______________________________________________________
Physician Signature
SummaCare Use Only
You will be notified if your request is not approved.
GENETIC TESTING REQUEST FORM (1 of 1)
In order for us to respond to you quickly, please:
Prior Authorization By Fax
1. Complete the request form in its entirety (see following
page—make copies for your use).
2. Include any supporting information and chart notes with your
request.
3. To allow for medical necessity review, please send requests at
least 48 hours prior to rendering service.
4. Complete clinical information will help to facilitate a quicker
authorization decision.
5. SummaCare will provide prior authorization within 48 hours of
receipt of request.
After a determination has been reached, an authorization specialist
will telephone you at your office to notify you of the
determination outcome. If you should have questions regarding the
above process, please call the Benefits Determination Unit at
330-996-8710 or 888-996-8710.
The fax number to submit a prior authorization request is
330-996-8904.
PRIOR AUTHORIZATION BY FAX (1 of 1)
CONFIDENTIAL Date:
Please fax to 330-996-8605 / 330-996-8904 or call 330-996-8710 /
888-996-8710 for urgent requests.
Member Last Name:
Member First Name:
Requesting Physician First & Last Name:
Practice/Group Name:
Physician Contact Name:
Diagnosis:
SummaCare Use Only
SummaCare Contact:
You will be notified by telephone if your request is not
approved.
PRIOR AUTHORIZATION REQUEST FORM (1 of 1)
Pharmacy Management
Revised: 09/03/14
SummaCare/Apex Medication Request Form
SUM01, 02, 03 (Part D), 06, 07
Attn: Prior Authorization Department
Fax: 8587907100
REQUEST FOR EXPEDITED (URGENT) REVIEW: BY CHECKING THIS BOX, I CERTIFY THAT APPLYING THE STANDARD REVIEW TIME
FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM
FUNCTION
Date: ______________ Time MRF was taken: ______________
Physician Signature: _____________________________________ Physician Cell Phone #: _____________
Medication Request Information (please complete each section of this form prior to transmittal): *Denotes Required Fields
Status
PHARMACY INFORMATION (If provided)
*Length of Treatment:
(Please be specific.)
Comments
Reason for Medication Request (Please be specific, give detail.):
Other Medications Tried and/or Failed including OTC (Please be specific, give detail. Chart notes preferred):
Other Pertinent History (Relative or pertaining to this request.):
**Note: Specialty Vendor is Walgreens Specialty: 8883473416
SummaCare is now partnering with TransactRx™ Vaccine Manager, which
is the nation’s leading solution for healthcare providers to
overcome the billing and reimbursement challenges associated with
administering vaccines covered by Medicare Part D. Providers no
longer have to write prescriptions for their patients to have their
Part D vaccines administered at a pharmacy or ask their patients to
pay out-of-pocket and then try to get reimbursed.
Benefits of TransactRx™ By signing one contract and enrolling with
TransactRx™ Vaccine Manager, you will be able to submit claims for
any Medicare Part D covered vaccine administered to members who
have a Part D plan that is contracted with TransactRx™. Other
benefits: • NO COST TO YOU. • Simple online enrollment process. •
Credentialing and acceptance into the network in less than 48
hours. • Simple web-based demonstration to learn how to utilize the
TransactRx™ Vaccine Manager system. • TransactRx™ Vaccine Manager
is contracted with Medicare Part D plans that represent over 80% of
all Medicare Part D covered lives. • Includes ALL Medicare Part D
covered vaccines. • Favorable negotiated reimbursement rates for
all Part D covered vaccines. • Ability to check status for
outstanding claims. • Payments are made to providers twice a month
via check or ACH. • Complete reporting is available to track and
manage claims and payments. How to Enroll Go to
http://enroll.mytransactrx.com/ to enroll. The following
information will be required, in addition to accepting TransactRx™
Vaccine Manager’s Agreement: • Tax Identification Number (TIN) •
National Provider Identifier(s) (NPI) • Medicare ID number • Drug
Enforcement Administration (DEA) number • State Medical License
number For questions on enrollment and claims processing, call
TransactRx™ Vaccine Manager’s customer support center at
866-522-3386. To enroll in the TransactRx™ Vaccine Manager program,
view a web demo or for more information, go to
http://enroll.mytransactrx.com/.
TRANSACT RX VACCINE MANAGER (1 of 1)
Utilization management restrictions include, but are not limited
to, prior authorization, step therapy, and quantity limits. Our
formulary and utilization management restrictions are developed,
reviewed and approved by the SummaCare Pharmacy and Therapeutics
Committee which is comprised of network physicians and
pharmacists.
To view the SummaCare utilization management restrictions for the
prescription drug benefits, visit www.summacare.com and click on
the Providers Tab, Resources & Self Services, and Pharmacy
Management.
Formulary documents can also be obtained on www.summacare.com for
the Commercial benefits and www.medicare.summacare.com for the
Medicare Part D Prescription Benefit. Click on the “Find Your Drug”
tab to view the latest SummaCare formulary documents.
PHARMACY MANAGEMENT DEPARTMENT SUMMARY (1 of 1)
CLAIM DENIALS – MEDICARE (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
__X__Medicare ____Commercial Fully
_X___Medicare ____Self-Funded ____BPO
Policy: Medicare members, when liable for payment, will receive a
detailed
explanation of the reason for the denial. Purpose: To ensure the
reason for non-payment of a claim is clearly identified and
appeal rights are provided to the member.
PROCEDURES
1. The system is configured to deny or pend claims for Processor
review for a number of reasons which include but are not limited
to:
• Member was not eligible at the time the service was rendered •
Benefits are not available for the services rendered • Services
exceed policy maximums • Claim is duplicate of a previously
processed claim • Unauthorized services (on applicable services) •
Provider chose to opt-out of participation in Medicare
2. When a claim denial results in member liability, a letter of
explanation is
generated. These letters include claim/service line information as
well as the procedures for filing an appeal.
POLICY NAME: CLAIM DENIALS – MEDICARE POLICY NUMBER: ISSUING DEPT.:
Claims EFFECTIVE DATE: 7/1/1996 APPROVED BY: Claude Vincenti
CLAIM DENIALS – MEDICARE (2 of 2)
The “Responsible Party” is the person responsible for ensuring that
this policy is reviewed and updated according to the Policy Review
Schedule.
COMPLIANCE STATEMENT: Enforcement: All employees are responsible
for complying with this policy.
Failure to abide by the conditions of this policy may result in
corrective action, up to and including termination. Employees are
responsible for reporting any observed violations of this policy in
according with the Compliance Communication and Reporting
Policy.
Review Schedule: This policy will be reviewed and updated as set
forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing
compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit
compliance with this policy.
Documentation: Documentation related to this policy must be
maintained for a minimum of 10 years.
Standards: MMCM Definitions: N/A Replaces: N/A Review Date:
9/16/2004, 9/1/2011, 8/4/2015 Revised Date:
3/12/1998, 10/18/2000, 9/16/2004, 9/1/2011, 8/4/2015
Responsible Party:
Melissa Stoner
HOSPICE SERVICES – MEDICARE (1 of 3)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
__X__Medicare ____Commercial Fully
_X___Medicare ____Self-Funded ____BPO
Policy: This policy describes the administration of hospice service
benefits for
Medicare beneficiaries. Purpose: To provide a consistent process
for the administration of the Hospice
benefit which are compliant with CMS guidelines.
PROCEDURES
1. When a beneficiary signs a Hospice Election Statement (provided
by Medicare Hospice Providers), the beneficiary must select and use
a Medicare certified hospice provider(s) for care related to the
terminal illness.
a. As of the first of the month after the beneficiary elects
hospice, the capitation from CMS to the client is reduced to an
administrative management fee per beneficiary per month. CMS places
the beneficiary in an administrative suspension status.
b. Care provided on or after the date of the hospice election, by
the hospice provider as it relates to the terminal diagnosis is
paid directly by CMS.
c. CMS is billed by non-hospice providers for care unrelated to the
terminal illness, (with the exception of the supplemental plan
benefits, e.g., eyeglasses, dental, prescription etc., which will
continue to be directed, provided and paid for by the plan.)
d. When billing CMS, providers should follow CMS guidelines, using
the appropriate modifiers.
e. Beneficiaries can revoke hospice elections at any time to resume
curative care. If so revoked, the client will resume coverage for
the
POLICY NAME: HOSPICE SERVICES - MEDICARE POLICY NUMBER: ISSUING
DEPT.: Claims EFFECTIVE DATE: 9/16/2011 APPROVED BY: Claude
Vincenti
HOSPICE SERVICES – MEDICARE (2 of 3)
according to his/her benefit plan, the first of the following
month. The client will then begin receiving normal capitation
payments from CMS. Prior to the first of the month and after
revocation of the hospice benefit, beneficiary reverts to Original
Medicare.
2. The client is only responsible for the following in relation to
beneficiaries seeking
or receiving hospice care and services: a. Education for the
beneficiary regarding availability of hospice care b. Referral to a
Medicare hospice provider c. Pre-Hospice consultation/evaluation by
either the medical director or
employee of a hospice provider for beneficiaries who has not yet
elected hospice benefit (effective January 1, 2005) for complete
criteria see:
http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf
d. Covered care and services for conditions that are unrelated to
the beneficaries terminal illness
i. Plan providers must bill Medicare Carriers and Intermediaries
for the beneficiary's basic benefits, using fee-for-service
mechanisms for those services (applicable copayments also apply).
When billing CMS, providers should follow CMS guidelines, using the
appropriate modifiers.
ii. To ensure beneficiaries are receiving their full benefit for
non- hospice related services, basic benefits will be coordinated
with CMS not to exceed what the plan would have paid if they had
been the only payer. Appropriate co-pays and coinsurance will
apply.
iii. The plan is responsible for covering the beneficiary's
supplemental benefits (e.g., eyeglasses, prescription drugs), if
any, as long as the beneficiary uses a plan provider and remains
enrolled with the plan.
3. For assistance with payment determinations, refer to Appendix A
– FCC Hospice
Grid Beneficiary Signs Hospice Election Statement or Appendix B –
FCC Hospice Grid Beneficiary Revokes Hospice Election
Statement.
4. For Medicare coverage guidelines for Hospice Services, refer to
the Medicare Benefit Policy Manual (Pub.100-2), Chapter 9 -
Coverage of Hospice Services under Hospital Insurance at:
http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf.
Also see the Medicare Claims Processing Manual (Pub. 100-4),
Chapter 11 - Processing Hospice Claims at:
http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf.
COMPLIANCE STATEMENT: Enforcement: All employees are responsible
for complying with this policy.
Failure to abide by the conditions of this policy may result in
corrective action, up to and including termination. Employees are
responsible for reporting any observed violations of this policy in
according with the Compliance Communication and Reporting
Policy.
Review Schedule: This policy will be reviewed and updated as set
forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing
compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit
compliance with this policy.
Documentation: Documentation related to this policy must be
maintained for a minimum of 10 years.
Standards: MMCM Definitions: N/A Replaces: N/A Review Date:
5/20/2013, 7/17/2013, 8/4/2015 Revised Date:
5/20/2013, 7/17/2013, 8/4/2015
Responsible Party:
Melissa Stoner
The “Responsible Party” is the person responsible for ensuring that
this policy is reviewed and updated according to the Policy Review
Schedule.
INTEREST PAYMENTS – FI & SF (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
__ __Medicare __X_Commercial Fully
___Medicare _X___Self-Funded __X__BPO
Policy: The outline the computation and payment of interest due per
ODI and
state regulations for clean and unclean claims. Purpose: To comply
with ODI and state requirements.
PROCEDURES
Fully Insured - Ohio Interest calculation is performed
automatically by the claims payment system on all claims. The
process uses the number of days late X 18%. Interest is paid at the
time the claim is paid. Self-Funded and Fully Insured (outside of
Ohio) The Legal Department will review the laws of the state in
which the self-funded client does business. If the state law
requires interest to be paid for late claims, interest will be
paid. The interest calculation will vary depending on the specific
rules of each state.
POLICY NAME: INTEREST PAYMENTS – FULLY INSURED AND
SELF-FUNDED
POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 7/1/2006
APPROVED BY: Claude Vincenti
INTEREST PAYMENTS – FI & SF (2 of 2)
COMPLIANCE STATEMENT: Enforcement: All employees are responsible
for complying with this policy.
Failure to abide by the conditions of this policy may result in
corrective action, up to and including termination. Employees are
responsible for reporting any observed violations of this policy in
according with the Compliance Communication and Reporting
Policy.
Review Schedule: This policy will be reviewed and updated as set
forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing
compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit
compliance with this policy.
Documentation: Documentation related to this policy must be
maintained for a minimum of 10 years.
Standards: Ohio SB #4 Definitions: N/A Replaces: N/A Review Date:
8/4/2015 Revised Date:
8/4/2015
Responsible Party:
Melissa Stoner
The “Responsible Party” is the person responsible for ensuring that
this policy is reviewed and updated according to the Policy Review
Schedule.
INTEREST PAYMENTS – MEDICARE (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
_X___Medicare ____Commercial Fully
_X___Medicare ____Self-Funded ____BPO
Policy: To outline the computation and payment of interest based on
Centers for
Medicare and Medicaid Services (CMS) requirements Purpose: CMS
requires interest to be paid on any service not finalzied within
thirty
days from the date of receipt of a clean claim from a
non-participating provider
PROCEDURES
claim amount X days late X interest rate 365
1) Interest calculation is performed programmatically on all
applicable services prior to the payable run. The process uses the
number of days late times the interest rate. Interest is paid at
the time the services are paid.
2) The interest rate is released twice a year and can be found
at
http://www.fms.treas.gov/prompt/rates.html. a) Configuration is
responsible for obtaining and updating the interest rate for
automated interest calculation within the claims processing
system.
3) The Claims Area uses databases to review services paying
interest when the amount of interest is over $10. This review is
based on pre-payable reports.
POLICY NAME: INTEREST PAYMENTS – MEDICARE POLICY NUMBER: ISSUING
DEPT.: Claims EFFECTIVE DATE: 4/28/1998 APPROVED BY: Dennis
Pijor
COMPLIANCE STATEMENT: Enforcement: All employees are responsible
for complying with this policy.
Failure to abide by the conditions of this policy may result in
corrective action, up to and including termination. Employees are
responsible for reporting any observed violations of this policy in
according with the Compliance Communication and Reporting
Policy.
Review Schedule: This policy will be reviewed and updated as set
forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing
compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit
compliance with this policy.
Documentation: Documentation related to this policy must be
maintained for a minimum of 10 years.
Standards: MMCM Definitions: N/A Replaces: N/A Review Date:
7/24/1998, 5/20/2013, 7/17/2013 Revised Date:
3/13/2007, 7/17/2013
Responsible Party:
Melissa Stoner
The “Responsible Party” is the person responsible for ensuring that
this policy is reviewed and updated according to the Policy Review
Schedule.
MEDICARE EXPLANATION OF BENEFITS (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
__X__Medicare ____Commercial Fully
Policy: SummaCare will comply with Medicare beneficiary explanation
of benefit
specificity requirements. Purpose: To ensure compliance with CMS
requirements regarding beneficiary
communications.
PROCEDURES EOB Procedure
A detailed EOB will be generated for each member weekly and a
summary EOB will be generated quarterly beginning 4/1/2014.
Beneficiaries may opt out of the EOB mailings via Plan Central.
EOBs will still be available for beneficiaries in Plan Central but
will no longer be mailed. Appeal rights will be included in the
weekly EOB when the member has a liability over and above
coinsurance, deductible and copay.
• FQ (unauthorized service – bill patient) • FR (services provided
are not considered medically
necessary) • FS (service is not a covered benefit, bill patient) •
FT (services have exceeded benefit limits of plan) • WZ (deny opt
out of Medicare Physicians and Practitioners)
POLICY NAME: MEDICARE EXPLANATION OF BENEFITS POLICY NUMBER:
ISSUING DEPT.: Configuration EFFECTIVE DATE: 4/1/2014 APPROVED BY:
Dennis Pijor
MEDICARE EXPLANATION OF BENEFITS (2 of 2)
• LK(submit to workers comp) • 90 (billed as maintenance care – not
a covered benefit) • SU(subrogation claim – third party
responsible)
Notice of denial letters will continue to be generated to further
explain the reason for denial.
COMPLIANCE STATEMENT: Enforcement: All employees are responsible
for complying with this policy.
Failure to abide by the conditions of this policy may result in
corrective action, up to and including termination. Employees are
responsible for reporting any observed violations of this policy in
according with the Compliance Communication and Reporting
Policy.
Review Schedule: This policy will be reviewed and updated as set
forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing
compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit
compliance with this policy.
Documentation: Documentation related to this policy must be
maintained for a minimum of 10 years.
Standards: MMCM Chapter 4 Definitions: N/A Replaces: N/A Review
Date: 8/4/2015 Revised Date:
N/A
Responsible Party:
Melissa Stoner
The “Responsible Party” is the person responsible for ensuring that
this policy is reviewed and updated according to the Policy Review
Schedule.
MEDICARE BENEFICIARY CLAIM REIMBURSE (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions
PRODUCT LINE(S): (Check all that apply)
__X__Medicare ____Commercial Fully
Policy: SummaCare will process claims submitted by Medicare
beneficiaries for
services that are covered by the plan when the member submits a
completed claim, including all necessary supporting
documentation.
Purpose: To develop guidelines for processing claims which are
submitted directly by Medicare beneficiaries requesting
reimbursement.
PROCEDURES The plan will: Process Medicare beneficiary submitted
claims for services when the beneficiary has submitted a complete
claim (Form CMS – 1490S) and all supporting documentation
associated with the claim. This includes:
• Date of service • Place of service • Description of illness or
injury • Description of each service received • Charge for each
service • The physician or suppliers name and address
If an incomplete claim or claim containing invalid information is
received, SummaCare will return the claim to the Medicare
beneficiary with a letter indicating specifically what information
is needed.
POLICY NAME: MEDICARE BENEFICIARY CLAIM REIMBURSEMENT POLICY
NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 2/18/2011 APPROVED
BY: Claude Vincenti
MEDICARE BENEFICIARY CLAIM REIMBURSE (2 of 2)
A copy of the claim will be retained in the document management
system. All covered services will be paid directly to the
beneficiary. The allowed amount is either the contracted rate for
contracted providers or the Medicare rate for non- contracted
providers. All non-covered services will be denied and a notice of
denial letter will be sent to the beneficiary. COMPLIANCE
STATEMENT: Enforcement: All employees are responsible for complying
with this policy.
Failure to abide by the conditions of