Determinations

We make determinations based only on the appropriateness of care and service and the existence of coverage. We don’t specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Furthermore, we don’t offer financial incentives to encourage inappropriate underutilization of covered services.

There are different rules for coverage determinations depending on whether you’re requesting coverage for prescription drugs or medical services.

If our initial decision is to deny your request (also called an adverse coverage determination), you can file an appeal.

If you or your doctor requests coverage for medical services, we must make a decision within 14 calendar days for a standard request.

If you or your doctor thinks waiting for a standard decision could seriously harm your health or ability to function, you can request an expedited or “fast” decision. We must respond to your request for a fast decision within 72 hours.

You may request an organization determination by one of the following methods:

By phone

Call the customer service department for your plan:

• HAP Senior Plus^®: (800) 801-1770 (TTY: 711)
• HAP Choice Medicare (HMO): (800) 801-1770 (TTY: 711)
• HAP Senior Plus^® (PPO): (888) 658-2536 (TTY: 711)
• HAP Primary Choice Medicare (HMO): (866) 766-4714  (TTY: 711)
• HAP Empowered Duals (HMO SNP): (800) 848-4844 (TTY: 711)
• Alliance Medicare Supplement: (800) 873-7526 (TTY: 711)

Our team members can take your call during the following times:

• 8 a.m. to 8 p.m., Seven Days a Week (Oct. 1 – March 31)
• 8 a.m. to 8 p.m., Monday through Friday (April 1 - Sept. 30)

At all other times, you may access our Interactive Voice Recording system at the same number and leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day. Please do not share personal health information when you leave your message.

By fax

(313) 664-5866

Through Medicare

https://www.medicare.gov/

In writing

Through the Message Center

1. Log in to your hap.org account.
2. Click on Message Center at the top of the page.
3. Click on Compose Message to send us a new message.

If you need to register for your online HAP account, have your ID card ready and go to hap.org/login. Click on Register now.

Quality of care issues

If you’re concerned about the quality of care you received, including care during a hospital stay, you also can file a complaint with an independent organization called Livanta LLC.

Write to or call Livanta:

Livanta LLC
BFCC-QIO Program
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701
1-888-524-9900
1-888-985-8775 (TTY)
Fax: 855-236-2423

For information on how to request an organization determination, click on the button below.

• How to request an Organization Determination (PDF) How to request an Organization Determination (PDF)

If you or your doctor requests coverage for a Medicare Part D prescription drug, we must make a decision within 72 hours for a standard request.

If you or your doctor thinks waiting for a standard decision could seriously harm your health or ability to function, you can request an expedited or "fast" decision. We must respond to your request for a fast decision with 24 hours.

You’re asking for an initial decision about prescription drug benefits if you:

• Ask for a Part D drug not on our drug list, also called a formulary. This is a request for a “formulary exception.”
• Ask for an exception for our plan’s utilization management techniques, such as step-therapy requirements or quantity limits. This also is considered to be a request for a “formulary exception.”
• Ask for a nonpreferred Part D drug at the preferred cost level. This is a request for a “tiering exception.”
• Ask us to pay for a prescription drug you’ve already received. This is a request for an initial decision about payment.

Learn more about exceptions for prescription drugs.

Pre-service requests for prescription drug benefits

Use the Request for Medicare Prescription Drug Coverage Determination form (PDF) to request prior authorization for a drug list drug, a formulary exception or a tiering exception.

Send the completed form, with appropriate documentation of medical necessity, to:

Fax: (313) 664-8045