Prior Authorization and Referrals
Prior Authorization means your doctor asks for permission before you get certain services, medicines, or referrals. We must approve these requests before you receive the service.You do not need a referral from your main doctor (PCP) to see a specialist. You also do not need a referral for routine eye care, chiropractic care, or mental health counseling. If you or your doctor want a referral for something that is not covered, please call Member Services at 1-844-366-2880. (TTY/TDD: 1-844-804-6086, Relay 711 We will talk about other options for you.
Some medical and mental health services may need Prior Authorization. If they do, your doctor will ask for it. We must review and approve these requests before you can get the service.
PRIOR AUTHORIZATION FOR SERVICES
Sometimes you may need care from a specialist. For some services, your doctor must ask SilverSummitHealthplan for approval before giving you that care. This is called prior authorization.
Your doctor will:
- Ask us for approval
- Explain why you need the service
- Share how it will help you
We will:
- Check if the service is covered
- Decide if it is medically necessary
- Respond in 2 business days
We will tell your doctor if the request is approved or denied. If you think the decision is wrong, you can ask for another review. This is called an appeal. You can find more about appeals in the “Member Satisfaction” section of your handbook.
You do not need approval for emergency room visits or care after an emergency. Always get help right awayif you have an emergency. You can ask your doctor if a service needs prior authorization or call Member Services at 1-844-366-2880, TTY: 1-844-804-6086, Relay 711.
PRIOR AUTHORIZATION FOR MEDICINES
Some medications also need prior authorization.
Your doctor will:
- Ask us to approve the medicine
- Share health info to help us decide
You may need approval if:
- The drug is not preferred
- You need special approval before getting it
- It is a drug given as a shot at the doctor’s office
- It is a specialty drug (see list on our website)
- You need more than the usual amount
- Other drugs should be tried first
While you wait, you can get up to a 4-day supply. We decide in 2 business days, and your doctor will be told the answer.
Call Member Services if you have questions: 1-844-366-2880, TTY: 1-844-804-6086, Relay 711.
Your Covered Benefits
SilverSummit Healthplan covers many health services.
Some of these services need:
- A doctor’s order
- Approval from SilverSummit before you get care (this is called prior authorization)
If you’re not sure if a service needs approval, call Member Services at 1-844-366-2880, TTY: 1-844-804-6086, Relay 711.
| Services | What's Covered | Needs Approval? |
| Allergy Care | Covered. Some limits apply. | Yes, for some |
| Ambulance (Emergency) | Ground or air (helicopter) ambulance | No |
| Behavioral Health | Includes mental health help, therapy, hospital stays, and more. | Yes, for some services |
| *Breast Cancer Screening | Once a year | No |
| Breast Pumps | Covered | Yes |
| Chiropractic Services | Under 21 with referral. Limit: 4 visits/year. | Yes, after 4 visits |
| Durable Medical Equipment (DME) | Medical items your doctor orders | Yes, in some cases |
| Prescription Drugs | Medicine your doctor orders | Yes, for some |
| Over-the-Counter (OTC) Drugs | Must have a doctor’s prescription | No |
| Well-Child Exams (EPSDT) | For children under 21. Includes school and sports checkups. | No |
| Eye Care & Glasses | Under 21: every 12 months; 21+: every 24 months; glasses once a year | No |
| Family Planning | Exams, screenings, pregnancy tests | No |
| Foot Care | For kids under 21. Orthotics for some conditions | Yes, in some case |
| Hearing Aids | Cochlear implants covered | Yes |
| High-Risk Pregnancy & Baby Care | Special support for extra health needs | Just notify the plan |
| Home Health Care | Ordered by doctor; care at home | Yes |
| Hospice Services | Care for end of life | Yes |
| Child Immunizations | For Members under 21 | No |
| Hospital Care (Inpatient & Outpatient) | Surgery and hospital stays | Yes, even for observation stays |
| Maternity Care | Care before and after birth. Tell us you’re pregnant | No |
| Lab Tests | Some tests not covered. | Yes, in some cases |
| Nurse Midwife Services | Covered if provider is in network | Yes, if out-of-network |
| OB Ultrasounds | 2 per pregnancy; more if specialist orders | Yes, if more than 2 |
| Doctor Visits (Office Visits) | Covered if in-network | Yes, if out-of-network |
| Orthotics/Prosthetics | Covered | Yes |
| Pain Management | Not for post-surgery pain | Yes |
| Physicals & Health Visits | One per year, or as needed | Yes, if out-of-network |
| Private Duty Nursing | Limited overnight care | Yes |
| Psychiatric Hospital Services | Covered | Yes |
| Psychiatric & Psychology Services | Mental health services | Yes, for some |
| Clinical Trials | Routine costs are covered | Yes |
| X-rays & Scans (Radiology) | CT, MRI, other high-tech scans | Yes, for high-tech scans |
| Reconstructive Surgery | Cosmetic-only surgery not covered | Yes |
| Rehabilitation services | Physical rehab and therapy | Yes |
| Skilled Nursing Facility Care | Comfort items not covered | Yes |
| Sterilization (like tying tubes) | Consent form required 30 days before | No |
| Therapy (PT, Speech, Occupational) | Covered | Yes |
| Stop Smoking Help | Includes patches, gum, and quit program | No |
| Surgery | Covered | Yes (except in emergencies) |
| Transplants | Covered if medically needed and not experimental | Yes |
| Urgent care | Quick care for non-emergencies | 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.
Lab Tests and What They Cover:
- Kids on Medicaid must get a blood test to check for lead when they are 1 year old and again when they are 2 years old.
- Other lab tests might be needed depending on the child’s age. These are based on health checkup guidelines from Bright Futures.
- *Breast Cancer Screening: Women who are 40 years old or older can get this check-up every year. Younger women might also get it if a doctor says it’s needed because of health risks, like if someone in their family had the same problem or if it runs in their genes.