SilverSummit Health Plan (Ambetter) Prior Authorization

SilverSummit Health Plan (Ambetter) prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Prior authorization is required for some services and is a condition of reimbursement for covered services subject to the plan’s authorization rules. SilverSummit states that out-of-network services generally require prior authorization (excluding ER and family planning), emergency room and post-stabilization services never require prior authorization, and urgent/emergent admissions require notification within one business day after admission. Standard requests should be submitted at least five business days before scheduled service or as soon as the need is identified. Most routine authorizations are processed within five business days; if additional clinical review is needed, determination can take up to 14 calendar days. Authorization requests may be submitted by fax, phone, or secure web portal. Some limited-scope services are delegated to vendors such as TurningPoint.
• Use the pre-auth tool and current provider manual because requirements vary by service and delegated vendor.
• Failure to obtain authorization may result in administrative claim denials.
• For out-of-network services, prior authorization is generally required except ER and family planning.
• The site references a prior authorization list/tool, but the list was not directly captured in the retrieved materials.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• fax

• phone

• secure web portal

• Submission resource 1

• Submission resource 2

• Submission resource 3

Information commonly required

• necessary clinical information
• all relevant member/service information for medical necessity review
• for delegated TurningPoint cardiac requests: clinical information uploaded through TurningPoint portal

Turnaround notes and caveats

• Standard requests: at least 5 business days before scheduled service, or as soon as need is identified.
• Routine authorizations: typically within 5 business days.
• If additional clinical information or Medical Director review is needed: up to 14 calendar days.
• Urgent/emergent admissions: notify within 1 business day after admit date.
• TurningPoint materials state limited-scope procedures may be reviewed by TurningPoint; the delegation scope is not generalized across all services.
• Use the pre-auth tool and current provider manual because requirements vary by service and delegated vendor.
• Failure to obtain authorization may result in administrative claim denials.
• For out-of-network services, prior authorization is generally required except ER and family planning.
• The site references a prior authorization list/tool, but the list was not directly captured in the retrieved materials.

Provider resources

• Provider Resources landing page (official)
• Provider Manuals (official)
• Prior Authorization (official)
• Electronic Transactions (official)
• Provider Toolkit (official)
• Provider Portal login (official)
• Medicaid Pre-Auth tool (official)
• TurningPoint cardiac program notice (official)

Sources