Initial Determination
The initial determination we make is the starting point for dealing with requests you may have about covering a Part C medical care or service you need, or paying for a Part C medical care or service you already received. Initial decisions about Part C medical care or services are called "organization determinations." With this decision, we explain whether we will provide the Part C medical care or service you are requesting, or pay for the Part C medical care or service you already received.
When we make an "initial determination" we are giving our interpretation of how the benefits and services are covered for members of the plan apply to your specific situation. If our initial decision is to deny your request you may appeal the decision. You may also appeal if we fail to make a timely initial decision on your request.
Who may ask for an Initial Determination?
You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your "appointed representative." You may name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you who is not already authorized under State Law then you and that person must sign and date an Appointment of Representative form that gives the person legal permission to be your appointed representative. This Appointment of Representative form must be included with the coverage determination request. To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.
Fast Decisions (Initial Determination):
A "fast" decision is also called an "expedited decision". The decision is made quickly (typically within 72 hours.) You may ask for a "fast" decision only if you or any doctor believe that waiting for the standard decision could seriously harm your health or your ability to function. Requests for an expedited initial determination can be made through Member Services by calling 1-877-615-4022 or by fax 386-676-7149. From November 15 through March 1 of each year the hours of operation are 7 days a week from 8 a.m. to 8 p.m. From March 2 through November 14 of each year the hours of operation are Monday through Friday, 8 a.m. to 8 p.m. The hearing impaired may call TTY 1-877-260-8312.
Standard Decisions (Initial Determination):
A standard decision about medical care is typically made within 14 days. We can extend the timeframe up to 14 days if you ask for the extension or if we justify a need for additional information and the delay is in your best interest.
A standard decision about payment for care you have already received can take up to 30 days or more. If you have not received an answer from us within 60 days of your request for payment, you can appeal this decision.
You, your prescribing physician, or your appointed representative may check on the status of your Initial Determination request at any time by contacting our Member Services Department at 386-615-4022 or 1-877-615-4022 From November 15 through March 1 of each year the hours of operation are 7 days a week from 8 a.m. to 8 p.m. From March 2 through November 14 of each year the hours of operation are Monday through Friday, 8 a.m. to 8 p.m. The hearing impaired may call TTY 1-877-260-8312.
- Members of the Medvantage Plan please refer to Section 5 of your Evidence of Coverage for complete information regarding the initial determination process and timeframes.
- Members of the Medvantage Rx & Rx Plus Plans please refer to Section 5 of your Evidence of Coverage for complete information regarding the initial determination process and timeframes.
