Coverage Decisions and Part D Coverage Determinations
Coverage Decisions for Health Care
A coverage decision is a decision we make about:
- Your health care products and services coverage or
- About the amount we will pay for your medical services or medical drugs.
For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from the doctor or if your network doctor refers you to a medical specialist.
You can also contact us and ask for a coverage decision if your doctor:
- Is unsure if we will cover a health care product or service or
- Refuses to provide medical care you think that you need.
If you want to know if we will cover a health care product or service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you when we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare.
If you disagree with this coverage decision, you can request an appeal.
For a standard decision:
- We will give you our answer within 14 days of receiving your request.
- We can take up to 14 more days ("an extended time period") for certain issues. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.
When you file a fast complaint, we will give you an answer to your complaint within 24 hours. If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.
If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
You can ask our plan to make a coverage decision on the medical care you are requesting. Based on your health, if you need a quick response, you should ask us to make a "fast decision."
To get a fast decision, you must meet two requirements:
- You can get a fast decision only if you are asking for coverage for health care you have not yet received. You cannot get a fast decision if your request is about payment for medical care you have already received.
- You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that because of your health the request needs a "fast decision", we will automatically agree to give you a fast decision. If you ask for a "fast decision" on your own, without your doctor's support, our plan will decide if your health requires that we give you a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter (and we will use the standard deadlines instead).
This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you asked for.
A fast decision means we will answer within 72 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.
Coverage decisions can be requested by mail, by phone, by fax to:
|EmblemHealth Medicare HMO
ATTN: Utilization Management
55 Water Street
New York, NY 10041-8190