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, items, 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, Texas Medicaid prescription drugs, and Texas Medicaid over-the-counter drugs.
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
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. The call is free.
2. Mail to:
MMP Clinical Department
5959 Corporate Dr. Suite 1300
Houston, TX 77036
3. Fax to 1-866-959-1537
Requests for coverage of a drug under Part D
You or your appointed representative can ask for a coverage decision in one of these ways:
1. Call Pharmacy Member Services at 1-833-232-1711 (TTY: 711) 24 hours a day, 7 days a week.
2. Mail to:
Attention: Pharmacy Department
PO Box 47686
San Antonio, TX 78265-8686
3. Fax to: 1-844-494-8342
4. Submit a Coverage Determination form
Your doctor can submit a request on your behalf through the online prescriber portal.
Unless additional clinical information is required, we have 72 hours to review a standard request and 24 hours to review an urgent request for a drug you have not yet received. For payment for a drug you already bought, we have 14 calendar days after we get your request to review. If we don’t give you our decision within 72 hours for a standard coverage decision, 24 hours for a fast coverage decision, or 14 calendar days for payment for a drug you already bought, 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. The standard 72-hour deadline could cause serious harm to your health or hurt your ability to function.
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.
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?
Unless additional clinical information is required, we have 72 hours to review a standard request and 24 hours to review an urgent request. If we don’t give you our decision within 72 hours for a standard coverage decision or 24 hours for a fast coverage decision, we will forward your request to the Independent Review Entity (IRE).
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 HHSC Office of the Ombudsman works as an advocate on your behalf. They can answer questions if you have a problem or complaint and can help you understand what to do. The HHSC Office of the Ombudsman also helps people enrolled in Texas Medicaid with service or billing problems. They are not connected with our plan or with any insurance company or health plan. The HHSC Office of the Ombudsman is an independent program, and their services are free.
You can reach the Office of the Ombudsman at 1-866-566-8989 (TTY: 1-800-735-2989) Monday through Friday from 8 a.m. to 5 p.m. Central time.
H8786_22_3001603_R CMS Approved 01/21/2022