Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or prescription drugs.

• A coverage decision about medical care or Medicare Part B prescription drugs is called an organization determination.
• A coverage decision about a Part D prescription drug is called a coverage determination.

The sections below provide more information about each of these types of coverage decisions and how to ask Peoples Health for a coverage decision.

When a coverage decision involves your medical care, it is called an organization determination.

Some examples of an organization determination are:

• If you want our plan to decide if we will cover certain medical care you want and you believe that this care is covered by our plan
• If you have received and paid for medical care that you believe should be covered by the plan and you want to ask our plan to reimburse you for this care
• If you have received medical care that you believe should be covered by the plan, but we have said we will not pay for this care

You can ask us for an organization determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative.

If your health requires a quick response, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section.

Mail: Submit a written request for an organization determination at the address listed in your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. Find your Evidence of Coverage under the Links to Plan Documents section below.

Phone: You may call the customer service number on your ID card.

Fax: Fax a written request for an organization determination to the fax number listed in your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. Find your Evidence of Coverage under the Links to Plan Documents section below.

For a standard organization determination, we will give you an answer as quickly as your health condition requires, but no later than 14 days after receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.

• However, for a request for a medical item or service, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.
• If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Appeals and Grievances.
• If we do not give you our answer within 14 calendar days (or, if there was an extended review period, by the end of that period), or within 72 hours if your request is for a Part B prescription drug, you have the right to file an appeal. See Appeals and Grievances for more information.

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.

• If your request was for us to pay our share of the bill for medical care you already received, and we determine that the care you paid for was not covered or did not follow plan rules, we will send you a letter that says we will not pay for these services and why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.

If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:

• You must be asking for coverage for medical care you have not yet received. You cannot ask for an expedited determination if your request is about payment for medical care you have already received.
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires an expedited determination, we will automatically agree to give you an expedited determination.

If you ask for an expedited determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited determination, we will process your request as a standard organization determination and notify you of our decision to process your request as a standard determination by sending you a letter. Our letter will indicate that we will automatically give you an expedited determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard determination instead of an expedited determination. For more information about grievances, see Appeals and Grievances.

If you meet the requirements for an expedited determination, we will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.

• However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more days to make our decision. We will let you know if we decide to do this.
• If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Appeals and Grievances.
• If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), or within 24 hours if your request is for a Part B prescription drug, you have the right to file an appeal. See Appeals and Grievances for more information.

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.

When a coverage decision involves your Part D prescription drugs, it is called a coverage determination.

Some examples of a coverage determination are:

• If you ask us to make an exception,* including:
  • Asking us to cover a Part D drug that is not on the plan’s formulary (our list of covered drugs)
  • 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)
  • Asking to pay a lower cost-sharing amount for a covered drug
  • Asking us to pay for a prescription drug you have already bought
  • If you ask us if a drug is covered for you and whether you satisfy any applicable coverage rules

*Please note: If you are requesting an exception, you will also need to provide a supporting statement from your doctor or prescriber that explains the medical reason why you need the exception approved.

For information on the total number of grievances, appeals or formulary exceptions submitted to Peoples Health, contact us.

You can ask us for a coverage determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative.

If your health requires it, you can ask us to make a “fast coverage decision,” which is also called an “expedited coverage determination.” More information about standard coverage determinations and expedited coverage determinations is available in this section.

To make your own request
Note: For certain requests, you’ll also need a supporting statement from your doctor.

Call:
You may call the customer services number on your ID card, and have this information handy:

• Member name
• Member date of birth
• Member ID number
• Name of medication
• Physician’s name
• Physician’s phone number
• Physician’s fax number (if available)

Mail:
Optum Rx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799

Medicare Part D Coverage Determination Request Form – (for use by members and providers)

Online: Log on to www.optumrx.com to submit a request.

• If you’re a new user to www.optumrx.com, you’ll need to register first.
• After you register, look for the Prior Authorization tool under Benefits and Claims > Prior Authorization.
• When you submit your request, Optum Rx will attempt to contact your doctor to get a supporting statement and/or additional clinical information needed to make a decision.

To have your doctor make a request

Your doctor or provider can contact Optum Rx at 1-800-711-4555 for the prior authorization department to submit a request.

The plan’s decision on your request will be provided to you by telephone and/or mail. In addition, the initiator of the request (your doctor or provider) will be notified by telephone and/or fax.

Your doctor can also request a coverage decision by going to Optum Rx Prior Authorization.

For a standard coverage determination about a drug you have not yet received:

• We will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request or your doctor’s supporting statement (if required).
• Remember, if your coverage determination request is for an exception, a supporting statement from your doctor or prescriber that explains the medical reason why you need the exception is required; we will give you our answer within 72 hours after we receive your doctor’s or other prescriber’s supporting statement.
• If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals and Grievances for more information.

For a standard coverage determination about payment for a drug you have already bought:

• We will give you our answer within 14 calendar days after we receive your request
• If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals and Grievances for more information.

If your request is about a drug you have not yet received and our answer is “YES” to all or part of what you requested, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 72 hours  after we receive your request or doctor’s statement supporting your request.

If your request is about payment for a drug you have already received and our answer is “YES” to all or part of what you requested, we must send any payment due to you within 14 calendar days after we receive your request.

For any coverage determination request, if our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.

If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:

• You must be asking for a drug you have not yet received. You cannot ask for an expedited coverage determination if you are asking us to pay you back for a drug you already bought.
• 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 an expedited coverage determination, we will automatically agree to give you an expedited determination. 

If you ask for an expedited coverage determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited coverage determination, we will process your request as a standard coverage determination and notify you of our decision by sending you a letter. Our letter will indicate that we will automatically give you an expedited coverage determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard coverage determination instead of an expedited coverage determination. For more information about grievances, see the Appeals and Grievances page.

If you meet the requirements for an expedited coverage determination, we will give you an answer as quickly as your health condition requires, but no later than 24 hours after receiving your request or your doctor’s supporting statement (if required).

• If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See the Appeals and Grievances page for more information.

If our answer is “YES” to all or part of what you requested, we will provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 24 hours after we receive your request or doctor’s statement supporting your request.

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal,  see Appeals and Grievances.