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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 drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her, or your network doctor might refer you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Coverage Decision for Medical Care

For more information on the medical care coverage decision process, you may refer to Chapter 9, Section 5 of the Evidence of Coverage (EOC).

If your health requires a quick response, you should ask us to make a “fast coverage decision.”

  • Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.
    • Call: 866-333-3530. Hours are 8 am to 8 pm, seven days a week from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.
    • TTY 711: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
    • Fax: 1-866-207-6539
    • Write:
      • CCA Health California
        Member Services Department (Coverage Decisions)
        18000 Studebaker Road, Suite 150
        Cerritos, CA 90703

Click here to download the Medical Coverage Decision (Organization Determination) Request Form:

Medical Coverage Decision Request Form (English)

Medical Coverage Decision Request Form (Spanish)

Download Adobe Acrobat Reader1

For expedited requests, please call or fax using the contact numbers above.

Generally we use the standard deadlines for giving you our decision

When we give you our 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 14 calendar days after we receive your request.

  • However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. 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 your health requires it, ask us to give you a “fast coverage decision”

  • A fast coverage 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 (such as medical records from out-of-network providers), 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. We will call you as soon as we make the decision.
  • To get a fast coverage decision, you must meet two requirements:
    • You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
    • 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 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 support, we will decide whether your health requires that we give you a fast coverage decision.
    • 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).
    • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.

Deadlines for a “fast coverage decision”

  • Generally, for a fast coverage decision, we will give you our answer within 72 hours.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or 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 detailed written explanation of why we said no.

Deadlines for a “standard coverage decision”

  • Generally, for a standard coverage decision, we will give you our answer within 14 calendar days of receiving your request.
  • 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 calendar days after we received your request. If we extended the time needed to make our coverage decision, we will authorize or 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.

If we say no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.

If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

Coverage Decision for Drugs

For more information on the drug coverage decision process, you may refer to Chapter 9, Section 6 of the Evidence of Coverage (EOC).

If your health requires a quick response, you must ask us to make a “fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

What to do:

  • Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our website. For the details, go to Chapter 2, Section 1 and look for the section called “How to contact us when you are asking for a coverage decision about your Part D prescription drugs.” Or if you are asking us to pay you back for a drug, go to the section called “Where to send a request that asks us to pay for our share of the cost for medical care or a drug you have received.”
    • Call: 888-254-9907. Calls to this number are free. Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.
    • TTY 711: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
    • Fax: 1-858-790-7100
    • Write:
      • MedImpact HealthCare Services
        Attn: Prior Authorization Department
        10181 Scripps Gateway Court
        San Diego, CA 92131

Click here to download the Drug Coverage Decision (Coverage Determination) Request:

Drug Coverage Decision Request Form (English)

Drug Coverage Decision Request Form (Spanish)

Download Adobe Acrobat Reader1

 

If your health requires it, ask us to give you a “fast coverage decision”

  • When we give you our 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 receive your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor’s statement.
  • To get a fast coverage decision, you must meet two requirements:
    • 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 your health requires that we give you a fast coverage decision.
    • 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).
    • This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells you how to file a “fast complaint,” which means you would get our answer to your complaint within 24 hours of receiving the complaint.

Deadlines for a “fast coverage decision”

  • If we are using the fast deadlines, we must give you our answer within 24 hours.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 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 written statement that explains why we said no. We will also tell you how to appeal.

Deadlines for a “standard coverage decision” about a drug you have not yet received

  • If we are using the standard deadlines, we must give you our answer within 72 hours.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 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 written statement that explains why we said no. We will also tell you how to appeal.

Deadlines for a “standard coverage decision” about payment for a drug you have already bought

  • We must give you our answer within 14 calendar days after we receive your request.
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
  • 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. We will also tell you how to appeal.

If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider—and possibly change—the decision we made.


Appointing a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Mailing Address:
CCA Health California
Member Services Department
18000 Studebaker Road, Suite 150
Cerritos, CA 90703
Fax Number: 1-866-207-6539


You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at 866-333-3530 (TTY: 711). Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

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