Coverage requests and determinations

Organization Determination

An Organization Determination is a decision Commonwealth Care Alliance® (CCA) makes about whether a medical item or service is covered. For example, it may include a wheelchair or other medical service.

Organization Determinations are also called service decisions. CCA will make a decision within 7 days of receiving the request.

Prior Authorization

Prior Authorization means we must review an item or service before agreeing to cover it. This helps make sure members receive the right item or service for their needs. You can track the status of your prior authorizations in CareSource MyLife.

Request an Organization Determination

You, your primary care provider (PCP), your care partner, or your appointed representative may request an Organization Determination. This includes asking for Prior Authorization.

There are four ways they can do this:

1. Provider Portal
2. Call: 1-866-610-2273 (TTY: 711)
3. Fax: 855-341-0720
4. Mail a written request to:
   Commonwealth Care Alliance
   Member Services
   P.O. BOX 8738
   Dayton, OH 45401-8738

For standard requests, CCA will make a decision within 14 days of receiving the request.

If your request is denied, you have the right to file an appeal.

Expedited Requests

An expedited request is decided within 72 hours. It is also called a fast coverage decision.

An expedited request may be approved if your care partner or provider shows that waiting for a standard decision could seriously harm your health or ability to function.

If CCA decides that your request does not qualify for an expedited review, we will notify you. We will then review your request using the standard 14-day timeframe.

If you disagree with that decision, you have the right to file an expedited grievance. This is also called a fast grievance.

If CCA denies your Organization Determination request, you have the right to file an appeal.

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Drug Coverage Determination

A Drug Coverage Determination is a decision CCA makes about whether a drug is covered. You have the right to ask CCA to cover a drug that is not usually covered.

Prior Authorization

Prior Authorization means we must review a drug before agreeing to cover it. This helps make sure you get the right drug for your condition.

CCA will usually approve a request only if a preferred drug or coverage restriction would not work as well for you or could cause harm.

Request a Drug Coverage Determination

You, your doctor, or your appointed representative may request a Drug Coverage Determination, including a Prior Authorization.

To request a Drug Coverage Determination, complete this form.

1. Mail or fax your form to:
   CVS Caremark
   Part D Appeals and Exceptions
   P.O. BOX 52000, MC109
   Phoenix, AZ 85072-2000
   Fax: 855-633-7673
2. Call: 1-833-251-9739 (TTY 711)
3. Submit the online form

CVS Caremark^® is CCA’s pharmacy benefit manager. They will review your request and make a decision.

For standard requests, a decision is made within 7 days after the request is received.

If waiting 72 hours could seriously harm your health, you or your doctor may request a fast coverage decision. This is also called an expedited request. For expedited requests, a decision is made within 24 hours. Your doctor must provide a statement supporting the need for an expedited request.

If your request is denied, you or your doctor have the right to file an appeal.

See your Member Handbook to learn more about Drug Coverage Determinations for Part D prescription drugs.

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Appointing a Representative

If you need someone to file an Organization Determination, Coverage Determination, or appeal for you, you may appoint a representative. This person can be a relative, friend, advocate, doctor, or another person you choose.

If you want someone to act for you, both of you must sign and date a statement giving that person permission to act on your behalf.

If you are making a request through an appointed representative, complete form CMS-1696 (pdf).¹ Then, mail or fax it to:

Commonwealth Care Alliance
Attn: Member Appeals
P.O. BOX 1947
Dayton, OH 45401-1947
Fax: 857-453-4517

If you have any questions about appointing a representative, call 1-866-610-2273 (TTY: 711).