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Coverage decisions

What is a coverage decision (determination)?

A coverage decision (determination) is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs.

Coverage decisions about your health care

A coverage decision about your health care is a decision about:

  • Your benefits and covered services, or
  • The amount we will pay for your health-care services.

Coverage decisions about your drugs

A coverage decision about your drugs is a decision about:

  • Your benefits and covered drugs, or
  • The amount we will pay for your drugs.

This applies to your Part D drugs, Medicaid prescription drugs, and Medicaid over-the-counter drugs.

Appointed representative

You can ask someone to represent you when you ask for a coverage decision. An appointed representative can be:

  • A relative
  • A friend
  • An advocate
  • A doctor

Fill out the Appointment of Representative form to have someone act on your behalf.

Requests about a non-Part D drug, Medicare-covered service or Medicaid-covered service

You, your doctor or appointed representative can ask for a coverage decision in one of these ways:

  1. Call Member Services at 1-855-878-1784 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time.
  2. Mail to:
    MMP Clinical Department
    7430 Remcon Circle, Building C, Ste. 120
    El Paso, TX 79912
  3. Fax to 1-844-206-3448

Requests about a Part D drug

You, your doctor or appointed representative can ask for a coverage decision in one of these ways:

  1. Call Member Services at 1-855-878-1784 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time.
  2. Submit a Medicare Prescription Determination Request form:

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).

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. Start by calling, writing, or faxing your request for us to cover the care you want.

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

You can get a fast coverage decision only if:

  1. You’re 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.)
  2. Your provider says you need a fast coverage decision.

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’ll 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.

We 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’ll 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, we’ll send you a letter telling 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. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision.

The Health and Human Services (HHS) Office of the Ombudsman helps act as a neutral party to solve members’ problems with their health plan.

The Office of the Ombudsman:

  • 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
  • Helps members understand their health benefits and work with their health plan
  • Helps members file appeals including utilization review appeals
  • Makes sure members have access to the Office of the Ombudsman and get answers timely

You can reach the Office of the Ombudsman at 1-877-787-8999 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Central time.

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 7/24/2018
H8786_18_35300_R CMS Approved 8/16/2018