Request Coverage / Organization Determination
Coverage Determination (Part D Prescription Drugs) As a member of Abrazo Advantage Health Plan (HMO) you have the right to request a coverage determination which is an initial coverage decision about your Part D prescription drugs.
Click below to learn more about AAHP's:
Prescription Drug Coverage Request for Determination
Organization Determination (Part C Medical)
As a member of Abrazo Advantage Health Plan you have the right to request an organization determination. An organization determination is an initial coverage decision we make about your benefits and coverage or the amount we will pay for your medical services.
Examples of organization determinations:
- Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services.
- Payment for any other health services furnished by a provider other than the Medicare health plan that you believe are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan.
- The Medicare health plan's refusal to provide or pay for services, in whole or in part, including the type or level of services, that you believe should be furnished or arranged for by the Medicare health plan.
- Discontinuation of a service if you believe that continuation of the service is medically necessary.
- Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide you with timely notice of an adverse determination, such that a delay would adversely affect your health.
If your request for an organization determination is denied, in whole or in part, you will receive a Notice of Denial of Medicare Coverage. If you do not agree with AAHP's determination, you have the right to file an appeal.
Please click here to learn how to file an appeal
For more information on coverage decisions refer to Chapter 9, Section 4 of your Evidence of Coverage.
H5985_246-2013 Pending CMS Approval