Prior Authorization and Referrals
Prior Authorization means your doctor has requested permission for you to get a special service, medication or referral. We must approve these requests before the delivery of services. You do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services. If you or your provider would like a referral to a service that is not a covered benefit, please call Member Services at 1-888-366-2880, TTY/TDD 711 so we can discuss other options available to you.
Some medical and behavioral health services may need Prior Authorization. If they do, your provider will arrange for authorization for these services. We must review these authorization requests before you can get the service.
Below is a list of services that require prior authorization from SilverSummit Healthplan before your healthcare provider can proceed with treatment.
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.