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Determinations, Exceptions, Appeals,
and Grievances

Learn how we make coverage decisions and how to request exceptions, appeal our decisions, and file a grievance.

  • What is an “organization determination”?

    An organization determination is a decision we make about whether medical items or services are covered. Organization determinations are also called coverage decisions.

    Asking for an organization determination
    You, your doctor, or your representative can contact us and ask for an organization determination if your doctor is unsure whether we’ll cover a particular medical service or if we refuse to provide medical care you think that you need. In other words, if you want to know if we’ll cover a medical service before you receive it, you can ask us to make an organization determination.

    In some cases, we might decide that a medical service is not covered or is no longer covered by Medicare. If you disagree with this coverage decision, you can make a medical care appeal.

  • What is a “coverage determination”?

    A coverage determination is a decision we make about whether a drug is covered by the plan. Coverage determinations are also called coverage decisions. If you don’t agree with a coverage determination, you have the right to make a pharmacy appeal.

  • What is an “exception”?

    If a drug isn’t covered in the way you want it to be, you can ask us to make an exception. If we turn down your request for a pharmacy exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need one. After receiving this explanation,we’ll consider your request.

  • What is an “appeal”?

    Medical care appeals
    If we say no to your request for coverage for medical care, you have the right to ask us to change this decision by making an appeal. Making a medical appeal means making another try to get the medical care coverage you want.
     

    Pharmacy appeals
    You also have the right to ask us to reconsider a decision we make about what prescription drugs are covered for you.
     

  • What is a “grievance”?

    A grievance is a complaint about anything other than benefits, coverage, or payment. You might file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You could also file a grievance if you did not think we responded quickly enough to your request for coverage determination or organization determination, or to your appeal of our decision.

    Learn how to file a grievance
     

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