Skip to Main Content

Prior Authorization and Referrals

Your Covered Benefits

SilverSummit Healthplan covers many medical services for your healthcare needs. Some services must be prescribed by your doctor. Some services must also be approved by SilverSummit Healthplan before you get the service.

ServicesDescription and LimitsPrior Authorization Required
Allergy care Yes, for some services
Ambulance – emergencyIncludes ground and emergency helicopter ambulance.No
Behavioral Health servicesAge limitations may apply. Services include crisis stabilization, inpatient psychiatric hospitalization, outpatient assessment and treatment services, residential treatment facilities and rehabilitation services.Yes, for some services
Breast pumps Yes
Chiropractic servicesCoverage is limited to Members under 21 years of age and referred from Early and Periodic Screening Diagnosis & Treatment(EPSDT) screening by their PCP. Limited to four visits per year.Yes, after four visits
Durable Medical Equipment (DME)Items that are not medically necessary, or are not ordered by a provider are not covered.Yes, in some situations
Drugs: prescription/pharmacy Yes, for some medications
Drugs: over-the-counter(OTC)Over-the-counter medications require a doctor’s prescription.No
Early and PeriodicScreening, Diagnosis and Treatment (EPSDT)/well child examServices are for members age 20 and younger. Well-Child exams, Sports and school physicals annually.No
Eye care services and eyeglassesUnder age 21, one exam every 12 months.Age 21 and older, one exam every 24 months. All members, lenses and frames every 12 months.No
Family planningFamily planning services can be from any Medicaid doctor or clinic. This includes well-woman exams, screenings and pregnancy testing.No
Foot careRoutine foot care is not covered. Foot care is covered for children under 21. Foot care visits may be limited. Orthotics are covered for some conditions.Yes, in some situations
Hearing aids and services Yes, for cochlear implants
High-risk prenatal andinfant servicesCare management provides special support for Members at risk or with special health needsNotify plan
Home healthcareCare must be prescribed by your doctor. And, not able to be received at the hospital or provider’s office. Other conditions apply.Yes
Hospice servicesOther than an inpatient facility.Yes
Immunizations for childrenAvailable to members age 21 and younger.No
Inpatient and outpatient hospital careItems that are not medically necessary are not covered.Yes, including observation services
Maternity careSee your provider as soon as you know you are pregnant. Send us the Notice of Pregnancy (NOP) form at first visit. Prenatal through postpartum services are covered. 
Lab services and testingPaternity testing and infertility treatment tests are not covered.Yes, in some situations
Nurse midwife servicesCovered with all in-network providers.Yes, for non-participating provider
Obstetric (OB) ultrasoundsTwo are allowed per pregnancy unless ordered by perinatologistYes, if more than two
Office visitsCovered with all in-network providers.Yes, for non-participating provider
Orthotics/prosthetics Yes
Pain managementNot applicable for post-operative pain management.Yes
Physician servicesOne routine physical exam every 12 months performed by your PCP. Health visits asneeded.Yes, for non-participating provider
Private duty nursing servicesOvernight nursing services and respite care hours are limited.Yes
Psychiatric hospital service Yes
Psychiatric services Yes, for some services
Psychology services Yes, for some services
Radiology and x-raysMust be ordered by a provider.Yes, for high-tech radiologyincluding CT, MRI, MRA
Reconstructive surgerySurgery that is performed to make you look better and is determined to be cosmetic is not covered.Yes
Rehabilitation services Yes
Skilled Nursing Facility careItems that are not medically necessary are not covered. This includes private rooms or convenience/comfort items.Yes
Sterilization servicesSterilizations require informed consent forms 30 days prior to the date of procedures. Hysterectomies are covered on a limited basis.No
Therapy (occupational,physical, speech) services Yes
Stop smoking/ tobaccocessationCertain medications, patches or gumto help you stop smoking are covered. Smoking cessation is covered through Tobacco-Free Nevada and National Jewish Health. Call 1-800-QUIT-NOW (784-8669)or 1-844-251-0004 for more information.No
Surgery Yes, except in an emergency
Transplant servicesFor Children under 21 years of age, anymedically necessary transplant that is not experimental will be covered. For Adults,Corneal, Kidney, Liver and Bone Marrow transplants will be covered if medically necessary.Yes
Urgent care No

NOTE: There are some services that your doctor has to get authorization before giving you the care. If you want to know if a service needs authorization, you can call Member Services. The phone number is 1-844-366-2880, TTY: 1-844-804-6086, Relay 711. There is more information about this later in the handbook. See the “Prior Authorization for Services” section. Some other benefits you can use are telemedicine, telemonitoring and telehealth.