Medical Decisions

What is a coverage determination?

A coverage determination is a decision we make about your benefits or coverage or about the amount we will pay for services. Read more about exceptions.

How do I request a coverage determination for both Medicare and Medicaid-covered services?

To ask for a coverage determination, you, your doctor, or your representative can call, write, or fax us. An appointed representative can be:

  • A relative
  • A friend
  • An advocate
  • A doctor
  • You can reach us at: 1-855-878-1784 (TTY 711)
  • You can fax us at: 1-844-206-3448
  • You can write to us at:
    MMP Clinical Department
    7430 Remcon Circle, Building C, Ste 120
    El Paso, TX 79912
If you are asking for a coverage determination
about a Part D drug

If you are asking for a coverage determination or redetermination about a Part D drug, you can call us or send a Medicare Prescription Determination Request form to:

Express Scripts
P.O. Box 14711
Lexington, KY 40512

ESI Pharmacy Services: 1-800-922-1557

How long does it take to get a coverage decision?

It usually takes up to 72 hours after you ask. If we don’t give you our decision within 72 hours, we will forward your request to the independent review entity (IRE).

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.” This is also called an expedited decision. If we approve the request, we will notify you of our decision within 24 hours.

To ask for a fast coverage decision: Start by calling, writing, or faxing our plan to ask us to cover the care you want.

You can call us at 1-855-878-1784 (TTY: 711). You can also have your provider or your representative call us.

What are the rules for asking for a fast coverage decision?

You can get a fast coverage decision only if:

  • You are asking about care you have not yet received. (You cannot get a fast coverage decision if your request is about care you have already received.)
  • If your provider says that you need a fast coverage decision, we will automatically give you one. If you ask for a fast coverage decision, without your provider’s support, we will decide if you get a fast coverage decision.

If we decide not to give you a fast coverage decision, we will use the standard 72-hour deadline instead.

We will also send you a letter.

  • This letter will tell you that if your provider asks for the fast coverage decision, we will automatically give you one.
  • 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 asked for.
How will I find out the plan’s answer about my coverage decision?

The plan will send you a letter telling you whether or not we approved coverage.

If the coverage decision is yes, when will I be able to get the service?

You will be authorized to get the service within 72 hours (for a standard coverage decision) or 24 hours (for a fast coverage decision) from the time you asked us.

What if the coverage decision is no?

If the answer is no, the letter we send you will tell you our reasons for saying No. If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.

What is the Office of the Ombudsman?

The Managed Care Office of the Ombudsman helps acts as a neutral party to solve members’ problems with their health plan.

What does the Office of the Ombudsman do?

  • Is an objective resource to help members work with their health plan
  • Looks into member complaints about managed care health plans
  • Helps members with enrollment and disenrollment issues
  • Offers information and referrals
  • Finds ways to improve the managed care program
  • Help members understand their health benefits and work with their health plan
  • Help members file appeals including utilization review appeals
  • Makes sure members have access to the Office of the Ombudsman and get answers timely

Hours of Operation: Monday through Friday from 8 a.m. to 5 p.m.
By Phone: 1-877-787-8999 (TTY 711)
By Mail: Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
PO Box 13247
Austin, TX 78711-3247
Website: https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman

Updated – 2/21/2018
H8786_18_33996_R CMS Approved 2/14/2018