Request Coverage Determination
Come and Learn How to Enroll
Read More InfoPrescription Drug Coverage Request for Determination
AAHP wants to provide you with thorough coverage and exceptional service in all aspects of your health care. Therefore, we have created various procedures to help you make special kinds of requests. As a member of AAHP, you can submit a Request for Coverage Determination.
What is coverage determination?
A coverage determination is a decision (approval or denial) made by AAHP regarding payment or benefits to which you believe you are entitled. Examples of this are:
- Whether to provide or pay for a part D drug
- Tiering exceptions
- Formulary exceptions
- Cost sharing for a drug
- Prior authorization requirements or step therapy restrictions
Click on each link to learn more about AAHP's:
Medical Coverage Request for Determination
A coverage determination is any determination made by a Medicare health plan with respect to any of the following:
- 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 the enrollee believes 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 the enrollee believes should be furnished or arranged for by the Medicare health plan
- Discontinuation of a service if the enrollee believes that continuation of the services 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 the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.
To view the Notice of Denial Of Medical Coverage, please click here.