Coverage Decisions for Medicare or Medi-Cal (not Part D drugs)
What is a coverage decision?
A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or Part B drugs. We also call this an Organization Determination. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.
Where can a coverage decision be filed?
You, your representative or your doctor can request a coverage decision by:
- Completing the Service Request form (PDF)
- Mailing your request to:
Attn: Member Services
12900 Park Plaza Drive, Ste #150
Cerritos, CA 90703
- Faxing your request to 1-888-371-3206
- Calling Member Services at 1-888-350-3447 (TTY: 711)
Monday - Friday 8 a.m. to 8 p.m. PST, except on holidays.
Your doctor does not need to complete the Appointment of Representative form for coverage decision requests.
How long does it take to get a coverage decision?
It usually takes up to 14 calendar days after you asked. If we don't give you our decision within 14 calendar days, you can appeal. Sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days.
If you need a response faster because of your health, you should ask us to make a "fast coverage decision." If we approve the request, we will notify you of our decision within 72 hours. However, sometimes we need more time and we will send you a letter telling you that we need to take up to 14 more calendar days.
Here are the rules for asking for a fast coverage decision:
You must meet the following two requirements to get a fast coverage decision:
- You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you have already received)
- You can get a fast coverage decision only if the standard 14-calendar-day deadline could cause serious harm to your health or hurt your ability to function
- If your doctor says that you need a fast coverage decision, we will automatically give you one
- If you ask for a fast coverage decision, without your doctor's support, we will decide if you get a fast coverage decision
- If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14-calendar-day deadline instead
Coverage Decisions for your Outpatient Drugs
What to do if you have problems getting a drug through your pharmacy benefit or you want us to pay you back for a drug:
You can ask for a Coverage Determination, also known as a Coverage Decision. Here are some examples of coverage decisions you can ask us to make about your pharmacy benefits.
- You ask us to make an exception
- You ask us for a drug that is on the plan's Drug List, but has certain limits and requires approval before we will cover it for you. You can use the Prior Authorization Criteria document to learn more about these limits. You can ask us to pay for a prescription drug you already bought. This is asking for a coverage decision about payment
What is an exception?
An exception is a type of coverage decision. An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs or is not covered in a way you would like, you can ask us to make an "exception."
When you ask for an exception, your doctor or other prescriber will need to explain the medical reason why you need the exception. Here are examples of exceptions:
- Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Drug List)
- Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
Important things to know about asking for exceptions
Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
How to ask for a coverage decision:
- Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You can also fill out an on-line request. You, your representative, or your doctor (or other prescriber) can do this
- If you are requesting an exception, provide the "supporting statement." Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the "supporting statement"
How to ask for a coverage decision for your pharmacy benefit:
Your prescriber does not need to complete the Appointment of Representative form for coverage decision requests.
Our plan has 72 hours (for a standard request) or 24 hours (for a fast request) from the date we get the required information to let you know our decision. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.
We will say Yes or No to your request for an exception
If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year for most drugs. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we say No to your request for an exception, you can ask for a review of our decision by making an appeal.
If your health requires it, ask us to give you a "fast coverage decision"
We will use the "standard deadlines" unless we have agreed to use the "fast deadlines."
- A standard coverage decision means we will give you an answer within 72 hours after we get your doctor's statement
- A fast coverage decision means we will give you an answer within 24 hours
- You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought)
- You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function
- If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision
If you ask for a fast coverage decision on your own (without your doctor's or other prescriber's support), we will decide whether you get a fast coverage decision.
If we decide to give you a standard decision, we will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a "fast complaint" and get a response within 24 hours.
- We will review your "fast complaint" and if we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead)
Who can make a coverage decision request?
Your doctor or other provider can ask for a coverage decision on your behalf. Your doctor or prescriber does not need to complete the Appointment of Representative form for coverage decision requests.
You can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
If you want a friend, relative, or other person to be your representative, call Member Services and ask for the "Appointment of Representative" form. You can also get the form on the Medicare website by clicking the link below. The form will give the person permission to act for you. You must give us a copy of the signed form with your request.
The form must include:
- Your name, address and phone number
- Your Medicare Health Insurance Claim Number (HICN) number
- The name, address and phone number of your representative
- Include a statement that you are giving permission for the representative to act on your behalf and are giving permission for personal information to be given to your representative
- Is signed by you and your representative
- Include a statement that your representative agrees to act on your behalf
CMS Link to Appointment of Representation form HERE.