A Coverage Determination is the initial decision we made about your coverage or payment for your prescription drug request. An Organization Determination is the initial decision we made about your coverage or payment for medical services. With this decision, we inform you whether we will provide the care or services you request (a pre-service decision), or pay for a service you have already received.
How determinations are made.
Utilization management decision-making is based only on the appropriateness of care and service and the existence of coverage. HAP does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Furthermore, HAP does not offer financial incentives to encourage inappropriate underutilization of covered services.
There are different rules for coverage determinations depending on whether you are requesting coverage for prescription drugs or coverage for medical services.
If our initial decision is to deny your request (which is also called an adverse coverage determination), you can file an Appeal.
Organization determinations about medical services.
If you or your doctor requests coverage for medical services, we must make a decision within 14 calendar days (for a standard request). If you or your doctor thinks that waiting for a standard decision could seriously harm your health or your ability to function, you can request an expedited or "fast" decision. We must respond to your request for a fast decision within 72 hours.
Coverage determinations about prescription drug benefits .
If you or your doctor requests coverage for a Part D prescription drug, we must make a decision within 72 hours (for a standard request). If you or your doctor thinks that waiting for a standard decision could seriously harm your health or your ability to function, you can request an expedited or "fast" decision. We must respond to your request for a fast decision with 24 hours. You are asking for an initial decision about prescription drug benefits if you:
- Ask for a Part D drug that is not on our formulary list. This is a request for a “formulary exception.”
- Ask for an exception for our plan’s utilization management techniques, such as step-therapy requirements or quantity limits. This is also considered to be a request for a “formulary exception.”
- Ask for a nonpreferred Part D drug at the preferred cost level. This is a request for a “tiering exception.”
- Ask us to pay for a prescription drug you have already received. This is a request for an initial decision about payment.
Pre-Service requests for prescription drug benefits.
Use the Medicare Part D Coverage Determination Request Form (PDF) to request prior authorization for a formulary drug, a formulary exception (coverage for a non-formulary drug) or a tiering exception.
Send the completed form, with appropriate documentation of medical necessity, to:
Health Alliance Plan Attn: Pharmacy Care Management
2850 W. Grand Blvd. Detroit, MI 48202
Fax: (313) 664-8045
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