Coverage Determinations, Appeals, and Exceptions
A coverage decision is a decision we make about your benefits, coverage, or the amount we’ll pay for your medical services or medicine. This decision is also called an organization determination when it is about a Part C medical benefit. It is called a coverage determination when it relates to a Part D prescription drug.
Part C Organization Determination
An organization determination is when South Country Health Alliance makes any decision regarding whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called “coverage decisions” in the AbilityCare Evidence of Coverage. Go to Chapter 9, Section 5 in your Evidence of Coverage for a more detailed explanation, or call Member Services and we can assist you.
How to Request an Organization Determination
- You can call us at 1-866-567-7242 (TTY 1-800-627-3529 or 711)
- You can fax us at 1-507-431-6328
- You can write us at:
Member ServicesSouth Country Health Alliance2300 Park Drive, Suite 100Owatonna, MN 55060
Part D Coverage Determination or Appeals
If your health care provider or pharmacist tells you that we will not cover a prescription drug or charges you more than you think your copay should be, you or your provider may contact us and ask for a Coverage Determination. The following are examples of when you can ask us for a Coverage Determination:
- If there is a limit on the quantity (or dose) of a drug and you disagree with the limit
- If there is a requirement that you try another drug before we will pay for the drug you are asking for
- If the copay for a drug is higher than expected
- If the drug is listed as non-formulary
If you or your provider do not agree with the outcome of the initial Coverage Determination, you or your provider may appeal the decision by having your provider request a Coverage Redetermination. This is also called an Appeal.
The process for requesting a Coverage Determination is discussed in more detail in Chapter 9 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, Appeals, and complaints).”
How to Request a Coverage Determination or Redetermination (Appeal)
There are 2 ways to request a Coverage Determination or Redetermination (Appeal). Either one of these 2 ways to request a Coverage Determination or Redetermination (Appeal) will be accepted.
1. By Phone
If you call us, we may need to get more information from your prescribing health care provider.
Start by calling Member Services.
2. By Mail or Fax
You and your prescribing health care provider can print and mail or fax one of the forms below.
Formulary Exception: Used to ask for coverage for a drug that is not on the formulary (not covered).
Formulary Exceptions are necessary for certain drugs that are eligible for coverage under the Medicare Part D benefit but not included on your formulary.
Your health care provider must submit a Request for Medicare Prescription Drug Coverage Determination (pdf) to SCHA for approval. If the request is not approved by the health plan, you have the option to Appeal the decision.
Prior Authorization: Required for some drugs before they will be covered.
Prior Authorization is only needed for certain drugs. If your health plan”s formulary guide indicates that you need a Prior Authorization for a specific drug, your health care provider must submit a prior authorization request form for approval. If the request is not approved, please remember that you always have the option to purchase the drug at your own expense.
Quantity Limits: Applied to some drugs based on the approved dosing limits established during the FDA approval process. Quantity limits are applied to the number of units dispensed for each prescription.
There are Quantity Limits for some drugs. If the List of Covered Drugs indicates that there is a Quantity Limit for a specific drug, your health care provider must submit a quantity limit exception form for approval. If the request is not approved you have the option to Appeal the decision.
Step Therapy: Requires you to try one or more drugs before coverage of a different drug is provided.
Step Therapy is used for some drugs. If the List of Covered Drugs reflects that Step Therapy is used for a specific drug, your health care provider must submit a step therapy exception form for approval. If the request is not approved, please remember that you always have the option to purchase the drug at your own expense.
These forms from the Centers of Medicare & Medicaid Services (CMS) can be used by all Medicare Part D prescribers and members.
Coverage Determination: Use this form if this is the first time you have asked for coverage of a specific drug.
Coverage Redetermination: Use this form if you want to Appeal a request that has been denied.
Completed forms can be mailed or faxed to:
Mail: South Country Health Alliance Attn: Health Services – Coverage Determinations 2300 Park Drive, Suite 100 Owatonna, MN 55060
Fax: South Country Health Alliance Standard: 1-855-446-7895 Expedited (fast): 1-855-446-7896
If you have already paid for Part D drugs covered by the plan, you can ask our plan to pay you back. Use the form below to request a reimbursement for the plan’s share of the cost of your Part D drugs. See Chapter 7 in your Evidence of Coverage for more information.
CMS Appointment of Representative
You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
You and the person you choose must sign, date, and complete a representative statement (see link to form below). A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement.
The representative statement must include your name and Medicare number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices, although it is not required.
More Information for AbilityCare