Summit Community Care utilizes Availity for prior authorization requests and status checks. While Availity doesn’t offer a specific “pre-check” tool, its Interactive Care Reviewer (ICR) allows providers to determine if prior authorization is needed for specific services or medications. This article outlines how to use Availity and other resources to navigate Summit Community Care’s prior authorization process.
Understanding Summit Community Care’s Prior Authorization Process
Prior authorization ensures certain medical services or medications are medically necessary before being covered by insurance. Summit Community Care streamlines this process primarily through Availity.
Using Availity for Prior Authorization
Availity acts as a central hub for managing prior authorizations. Registered providers can access the Interactive Care Reviewer (ICR) to:
- Submit Prior Authorization Requests: Initiate requests for various services and medications.
- Check Prior Authorization Status: Monitor the progress of submitted requests and view decisions.
Accessing ICR within Availity is straightforward:
- Log into your Availity account.
- Navigate to Patient Registration | Authorizations & Referrals.
- Select Authorizations to submit a new request or Auth/Referral Inquiry to check the status of an existing one.
Don’t have an Availity account? Register for free.
Example of a prior authorization portal within a healthcare system.
Prior Authorization Requirements by Service Type
Specific requirements for prior authorization vary depending on the type of service:
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Physical Health: Submit requests online via Availity or download and complete the Prior Authorization Form and fax it to 1-800-964-3627.
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Behavioral Health: Certain revenue codes (0240-0249, 0901, 0905-0907, 0913, 0917, 0944-0945, 0961) always require prior authorization. Submit requests online or fax them to designated numbers (Inpatient: 1-877-434-7578, Outpatient: 1-866-877-5229).
Chart depicting common behavioral health billing codes.
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Pharmacy: Refer to the Preferred Drug List (PDL) for covered medications. Some medications require prior authorization (revenue code 0632).
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Long-Term Services and Supports: Contact 1-844-462-0022 for authorization requests. Elective services at non-participating facilities and services with revenue codes 0023, 0570-0572, 0579, 0944-0945, and 3101-3109 always require prior authorization.
Utilizing the Preferred Drug List (PDL)
The PDL is a valuable resource for pharmacy prior authorizations. While it doesn’t include every covered drug, it highlights preferred options within common therapeutic categories. Consulting the PDL can help determine if a medication requires prior authorization.
Conclusion
While Summit Community Care doesn’t offer a standalone pre-check tool, Availity’s ICR functionality serves a similar purpose by enabling providers to determine the necessity of prior authorization and manage the entire process efficiently. Utilizing Availity, along with resources like the PDL and specific contact numbers for different service types, simplifies obtaining prior authorizations for Summit Community Care members. Refer to the Prior Authorization Lookup Tool and Prior Authorization Forms for further assistance.
