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Determinations

Understanding Medicare coverage decisions

Organization determinations

An organization determination is the first decision we make about your request for coverage or payment for a Medicare Part B drug or a medical service. 

Medicare Part B drugs are medications that are usually not self-administered. These drugs are typically supplied and given by a healthcare professional in a medical setting or require special equipment for administration.

Examples of Medicare Part B drugs include: 

  • Medications given through an intravenous (IV) infusion
  • Injectable drugs administered by a doctor or nurse
  • Respiratory medications used with a home nebulizer
  • Insulin used with an external infusion pump
  • Blood clotting factor products
  • Certain oral medications, such as:
    • Some oral cancer drugs
    • Oral anti-nausea medications taken after chemotherapy
    • Immunosuppressive drugs taken after an organ transplant 

A medical service is any healthcare service provided by a healthcare professional to help prevent, diagnose, treat or manage a medical condition, illness or injury. This can include procedures, treatments, tests or healthcare visits. They are not medications. Medical services are covered under your medical benefit.

Examples of medical services include:

  • Preventive care (such as Annual Wellness Visits and screenings)
  • Diagnostic services (such as lab tests, X-rays and imaging)
  • Doctor office visits
  • Surgical procedures
  • Therapeutic treatments
  • Emergency care
  • Hospital services
  • Chronic disease management

Coverage determinations

A coverage determination is the first decision we make about your request for coverage or payment for a Medicare Part D prescription drug.

Medicare Part D prescription drugs are prescription medications covered under your Medicare Part D prescription drug benefit. These medications are:

  • Prescribed by your healthcare provider
  • Filled at a retail, mail-order or specialty pharmacy
  • Usually taken or administered by you at home

Examples include: 

  • Blood pressure medications
  • Diabetes medications taken by month
  • Cholesterol medications
  • Antibiotics
  • Many self-injectable medications

Coverage decisions

With both organization and coverage determination decisions, we will inform you whether we'll provide the care/services you requested (a pre-service decision) or pay for the care/service you've already received.

We make determinations based only on the appropriateness of care and service, and the existence of coverage. We don’t specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Furthermore, we don’t offer financial incentives to encourage inappropriate underutilization of covered services.

There are different rules for coverage determinations depending on whether you’re requesting coverage for prescription drugs or medical services.

If our initial decision is to deny your request (also called an adverse coverage determination), you can file an appeal.

If you or your doctor requests coverage for medical services, we must make a decision within 7 calendar days for a standard request. If you or your doctor requests coverage for a Part B drug, we must make a decision in 72 hours for a standard request.

If you or your doctor believes that waiting 72 hours for a standard decision could seriously harm your health or ability to function, you can ask for an expedited (fast) decision. If your doctor indicates that waiting 72 hours could seriously harm your health, we will give you a decision for a Part B drug within 24 hours.

You may request an organization determination by one of the following methods:

Phone

HMO and HMO-POS plans

PPO plans

D-SNP and C-SNP plans

Our customer service representatives take calls during the following times:

  • Oct. 1 - March 31 from 8 a.m. to 8 p.m., seven days a week
  • April 1 - Sept. 30 from 8 a.m. to 8 p.m., Monday through Friday

At all other times, you may access our interactive voice recording system at the same number. Leave your name and phone number. A customer service representative will return your call the next business day. Please do not share personal health information when you leave your message.

Fax

Medical Services
For new authorization requests: (313) 664-5916
For clinical information for authorizations already created: (313) 664-5701
For Part B drug reviews: (313)-664-5338. 

Through Medicare

Visit the Medicare website to learn how to request an organization determination.

Mail

Medical Services
Health Alliance Plan
Attn: Appeal and Grievance Department
1414 E Maple Rd
Troy, MI 48083

Part B Drugs
Health Alliance Plan
Attn: Pharmacy Care Management
1414 E Maple Rd
Troy, MI 48083

Through the Message Center

  1. Log in to your member portal.

  2. Click on Message Center at the top of the page.

  3. Click on Compose Message to send us a new message.

If you need to register for the member portal, have your member ID card ready and go to hap.org/login.

If you or your doctor requests coverage for a Medicare Part D prescription drug, we must make a decision within 72 hours for a standard request.

If you or your doctor thinks waiting for a standard decision could seriously harm your health or ability to function, you can request an expedited (fast) decision. We must respond to your request for a fast decision with 24 hours.

You’re asking for an initial decision about prescription drug benefits if you ask for:

  • A Part D drug not on our drug list, also called a formulary. This is a request for a formulary exception.
  • An exception for our plan’s utilization management techniques, such as step-therapy requirements or quantity limits. This is also considered a request for a formulary exception.
  • A nonpreferred Part D drug at the preferred cost level. This is a request for a tiering exception.
  • Us to pay for a prescription drug you’ve already received. This is a request for an initial decision about payment.

Learn more about exceptions

Pre-service requests for prescription drug benefits

Use the Request for Medicare Drug Coverage Determination form to request prior authorization for a drug list prescription, a formulary exception or a tiering exception.

Send the completed form, with appropriate documentation of medical necessity, to:

Health Alliance Plan
Attn: Pharmacy Care Management
1414 E Maple Rd
Troy, MI 48083

Fax: (313) 664-8045

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