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What is a coverage determination request?

A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount youll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

What is Medicare coverage determination?

A coverage decision is a decision we make about your benefits, coverage or the amount well pay for your medical services or medicine. This decision is also called an organization determination when it is about a Part C medical benefit.

What is the turnaround time for a standard coverage determination?

How a Plan Sponsor Processes Coverage Determination Requests. For requests for benefits that do not involve exceptions, a plan sponsor must provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request.

What is the difference between coverage determination and prior authorization?

Types of Coverage Determination Requests If the request is not approved by the health plan, you have the option to appeal the decision. Prior Authorization Request: You must get our approval for some drugs before they will be covered. This is called prior authorization.

What is the coverage determination guideline?

Coverage Determination Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Coverage Determination Guidelines may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.

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What is the turnaround time for Medicare Part D prior authorization?

Once we receive your reimbursement request, a decision will be made within 14 calendar days. If approved, payment will be processed and mailed within the same 14 calendar days.

What are the five steps in the Medicare appeals process?

The Social Security Act (the Act) establishes five levels to the Medicare appeals process: redetermination, reconsideration, Administrative Law Judge hearing, Medicare Appeals Council review, and judicial review in U.S. District Court.

What is a coverage determination for Medicare?

LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MACs jurisdiction (region) in ance with section 1862(a)(1)(A) of the Social Security Act.

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