HAVE AN ENROLLMENT NEED? SHOP OUR PLANS
Handbooks & Forms for Members | Ambetter from SilverSummit HealthPlan
Member Resources
Many of our member resources, such as the member handbook and forms, can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!
Quick Reference Guide (QRG)
- 2023 Quick Reference Guide (QRG) (PDF)
- 2023 Quick Reference Guide (QRG) Value (PDF)
- 2022 Quick Reference Guide (QRG) Essential, Balanced & Secure Care (PDF)
- 2022 Quick Reference Guide (QRG) Value (PDF)
- 2022 Quick Reference Guide (QRG) Off-Exchange (PDF)
Reference Materials
- Get Your Flu Shot
- Preventive Services Guide (PDF)
- Dr. Office Visit Checklist (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- Where to go for Care
- Women's Health and Cancer Rights Act Annual Notice
- Ambetter In-Network Hemophilia Pharmacies
- Interoperability and Patient Access
- COVID-19 Home Testing Kits
- Cost Comparison Tool
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (PDF)
- Grievance and Appeals Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Member Reimbursement Form - OTC Covid Test (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)