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.

Services	Description and Limits	Prior Authorization Required
Allergy care		Yes, for some services
Ambulance – emergency	Includes ground and emergency helicopter ambulance.	No
Behavioral Health services	Age 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 services	Coverage 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 exam	Services are for members age 20 and younger. Well-Child exams, Sports and school physicals annually.	No
Eye care services and eyeglasses	Under 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 planning	Family planning services can be from any Medicaid doctor or clinic. This includes well-woman exams, screenings and pregnancy testing.	No
Foot care	Routine 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 services	Care management provides special support for Members at risk or with special health needs	Notify plan
Home healthcare	Care must be prescribed by your doctor. And, not able to be received at the hospital or provider’s office. Other conditions apply.	Yes
Hospice services	Other than an inpatient facility.	Yes
Immunizations for children	Available to members age 21 and younger.	No
Inpatient and outpatient hospital care	Items that are not medically necessary are not covered.	Yes, including observation services
Maternity care	See 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 testing	Paternity testing and infertility treatment tests are not covered.	Yes, in some situations
Nurse midwife services	Covered with all in-network providers.	Yes, for non-participating provider
Obstetric (OB) ultrasounds	Two are allowed per pregnancy unless ordered by perinatologist	Yes, if more than two
Office visits	Covered with all in-network providers.	Yes, for non-participating provider
Orthotics/prosthetics		Yes
Pain management	Not applicable for post-operative pain management.	Yes
Physician services	One routine physical exam every 12 months performed by your PCP. Health visits asneeded.	Yes, for non-participating provider
Private duty nursing services	Overnight 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-rays	Must be ordered by a provider.	Yes, for high-tech radiologyincluding CT, MRI, MRA
Reconstructive surgery	Surgery that is performed to make you look better and is determined to be cosmetic is not covered.	Yes
Rehabilitation services		Yes
Skilled Nursing Facility care	Items that are not medically necessary are not covered. This includes private rooms or convenience/comfort items.	Yes
Sterilization services	Sterilizations 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/ tobaccocessation	Certain 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 services	For 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.