Peoples Health Choices Plus (HMO)
Plan Details: Coverage Decisions
Coverage Decisions
This page provides general information about coverage decisions. The following topics are included:
» What is a coverage decision?
» Important Links, Documents and Forms
Coverage Decisions for Medical Care
» What is an organization determination?
» How do you ask for an organization determination?
» What is the timeline for a standard organization determination?
» What happens after Peoples Health makes a standard organization determination?
» What are the requirements for an expedited determination?
» What is the timeline for an expedited determination?
» What happens after Peoples Health makes an expedited determination?
Coverage Decisions for Prescription Drugs
» What is a coverage determination?
» How do you ask for a coverage determination?
» What is the timeline for a standard coverage determination?
» What happens after Peoples Health makes a standard coverage determination?
» What are the requirements for an expedited coverage determination?
» What is the timeline for an expedited coverage determination?
» What happens after Peoples Health makes an expedited coverage determination?
What is a coverage decision?
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or prescription drugs.
- A coverage decision about whether we will cover medical care is called an organization determination.
- A coverage decision about whether we will cover a Part D prescription drug is called a coverage determination.
The sections below provide more information about each of these types of coverage decisions and how to ask Peoples Health for a coverage decision.
Coverage Decisions for Medical Care
What is an organization determination?
When a coverage decision involves your medical care, it is called an organization determination.
Some examples of an organization determination are:
- If you want our plan to decide if we will cover certain medical care or services you want, and you believe that this care is covered by our plan
- If you have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care
- If you have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care
How do you ask for an organization determination?
You can ask us for an organization determination yourself, or your physician or someone else may act on your behalf and submit a request for you.
If your health requires it, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section.
You may call, write or fax our plan to submit an organization determination request. Our contact information is listed below:
Peoples Health
Member Services Department
Three Lakeway Center
3838 N. Causeway Blvd., Ste. 2200
Metairie, LA 70002
TTY users may call 711
Seven days a week, from 8 a.m. to 8 p.m. If you contact us on a weekend or on a holiday between February 15 and September 30, you may leave a message, and your call will be returned within one business day.
(504) 849-6906 – Fax
What is the timeline for a standard organization determination?
For a standard organization determination, we will give you an answer as quickly as your health condition requires, but no later than 14 days after receiving your request.
- However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this.
- If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Appeals and Grievances.
- If we do not give you our answer within 14 days (or, if there was an extended review period, by the end of that period), you have the right to file an appeal. see Appeals and Grievances for more information.
What happens after Peoples Health makes a standard organization determination?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the medical care coverage we have agreed to provide as quickly as your health condition requires, but no later than 14 days after we receive your request (or, if there was an extended time period for review, by the end of that period).
- If your request was for us to pay our share of the bill for medical care you already received, and we determine that the care you paid for is covered and followed plan rules, we will send you a payment for our share of the costs within 60 calendar days after we receive your request.
If our answer is “NO” to part or all of what you requested, we will send you a written statement that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.
- If your request was for us to pay our share of the bill for medical care you already received, and we determine that the care you paid for was not covered or did not follow plan rules, we will send you a letter that says we will not pay for these service and why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.
What are the requirements for an expedited determination?
If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:
- You must be asking for coverage for medical care you have not yet received. You cannot get an expedited determination if your request is about payment for medical care you have already received.
Using the standard deadlines could cause serious harm to your health or hurt your ability to function.
- If your doctor tells us that your health requires an expedited determination, we will automatically agree to give you a fast decision.
If you ask for an expedited determination on your own without your doctor’s support, we will decide whether your health requires that we give you a fast decision. If we decide your medical condition does not meet the requirements for an expedited determination, we will process your request as a standard organization determination and notify you of our decision to process your request as a standard determination by calling you and by sending you a letter. Our notification will indicate that we will automatically give you an expedited determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard determination instead of an expedited determination. For more information about grievances, see Appeals and Grievances.
What is the timeline for an expedited determination?
If you meet the requirements for an expedited determination, we will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request.
- However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more days to make our decision. We will let you know if we decide to do this.
- If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Appeals and Grievances.
- If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), you have the right to file an appeal. see Appeals and Grievances for more information.
What happens after Peoples Health makes an expedited determination?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the medical care coverage we have agreed to provide as quickly as your health condition requires, but no later than 72 hours after we receive your request (or, if there was an extended time period for review, by the end of that period).
If our answer is “NO” to part or all of what you requested, we will send you a written statement that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.
Coverage Decisions for Prescription Drugs
What is a coverage determination?
When a coverage decision involves your outpatient prescription drugs (Part D prescription drugs), it is called a coverage determination.
Some examples of a coverage determination are:
- If you ask us to make an exception,* including:
- Asking us to cover a Part D drug that is not on the plan's formulary (our list of covered drugs)
Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
- Asking us to pay a lower cost-sharing amount for a covered, nonpreferred drug
If you ask us to pay for a prescription drug you have already bought
- Asking us to cover a Part D drug that is not on the plan's formulary (our list of covered drugs)
- You ask us if a drug is covered for you and whether you satisfy any applicable coverage rules
*Please note: If you are requesting an exception, you will also need to provide a supporting statement from your physician, which is your doctor’s statement of the medical reason as to why you need the exception approved.
How do you ask for a coverage determination?
You can ask us for a coverage determination yourself, or your physician or someone else may act on your behalf and submit a request for you.
If your health requires it, you can ask us to make a “fast decision,” which is also called an “expedited coverage determination.” More information about standard coverage determinations and expedited coverage determinations is available in this section.
You may call, write or fax our plan to submit a coverage determination request. Our contact information is listed below:
Peoples Health
Member Services Department
Three Lakeway Center
3838 N. Causeway Blvd., Ste. 2200
Metairie, LA 70002
If you would like to use a standard form to submit your coverage determination request to us in writing, use the Request for Medicare Prescription Drug Coverage Determination Form.
Request for Medicare Prescription Drug Coverage Determination Form
Download PDF (28 KB)
TTY users may call 711
Seven days a week, from 8 a.m. to 8 p.m. If you contact us on a weekend or on a holiday between February 15 and September 30, you may leave a message, and your call will be returned within one business day.
(504) 849-6906 – Fax
You may also file a standard coverage determination online using the Request for Medicare Prescription Drug Coverage Determination Form.
Request for Medicare Prescription Drug Coverage Determination Form
Online Form
What is the timeline for a standard coverage determination?
For a standard coverage determination about a drug you have not yet received:
- We will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request.
- Remember, if your coverage determination request is for an exception, you will need to provide a supporting statement from your physician, which is your doctor’s statement of the medical reason as to why you need the exception approved. For exception requests, we will give you our answer within 72 hours after we receive your doctor’s supporting statement.
- If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals and Grievances for more information.
For a standard coverage determination about payment for a drug you have already bought:
- If we approve your request, we will give you our answer, along with any payment due, within 14 calendar days after we receive your request
- If we do not approve your request, we will give you our answer within 72 hours.
- If we do not meet these deadlines, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals and Grievances for more information.
What happens after Peoples Health makes a standard coverage determination?
If your request is about a drug you have not yet received and our answer is “YES” to all or part of what you requested, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 72 hours after we receive your request or doctor’s statement supporting your request.
If your request is about payment for a drug you have already received and our answer is “YES” to all or part of what you requested, we must send any payment due to you within 14 calendar days after we receive your request.
For any coverage determination request, if our answer is “NO” to part or all of what you requested, we will send you a written statement that explains why within 72 hours. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals and Grievances.
What are the requirements for an expedited coverage determination?
If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:
- You must be asking for a drug you have not yet received. You cannot ask for an expedited coverage determination if you are asking us to pay you back for a drug you already bought.
- Using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires an expedited coverage determination, we will automatically agree to give you a fast decision.
If you ask for an expedited coverage determination on your own without your doctor’s support, we will decide whether your health requires that we give you a fast decision. If we decide your medical condition does not meet the requirements for an expedited coverage determination, we will process your request as a standard coverage determination and notify you of our decision to process your request as a standard coverage determination by calling you and by sending you a letter. Our notification will indicate that we will automatically give you an expedited coverage determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard coverage determination instead of an expedited coverage determination. For more information about grievances, see the Appeals and Grievances page.
What is the timeline for an expedited coverage determination?
If you meet the requirements for an expedited coverage determination, we will give you an answer to as quickly as your health condition requires, but no later than 24 hours after receiving your request.
- If your coverage determination request was for an exception, we will give you our answer as quickly as your health condition requires, but no later than 24 hours after we receive your doctor’s supporting statement.
- If we do not meet this deadline, we are automatically required to send your expedited coverage determination request to level 2 of our appeals process. See the Appeals and Grievances page for more information.
What happens after Peoples Health makes an expedited coverage determination?
If our answer is “YES” to all or part of what you requested, we will provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 24 hours after we receive your request or doctor’s statement supporting your request.
If our answer is “NO” to part or all of what you requested, we will send you a written statement that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see the Appeals and Grievances page.
For more information about coverage decisions, please refer to Chapter 9 of your plan’s Evidence of Coverage. You can access your plan’s Evidence of Coverage, and other plan documents, here.
Important Links, Documents and Forms
Links to Plan Documents
» Peoples Health Choices 65 (HMO)
» Peoples Health Choices Plus (HMO)
» Peoples Health Choices Select (HMO)
» Peoples Health Secure Choice (HMO SNP)
» Peoples Health Secure Health (HMO SNP)
» Peoples Health Group Medicare (HMO-POS)Request for Medicare Prescription Drug Coverage Determination Form
Request for Medicare Prescription Drug Coverage Determination Form
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