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A coverage determination is the initial decision we make about your coverage or payment for a prescription drug request. An organization determination is the initial decision we make about your coverage or payment for medical services.
With these decisions, we inform you whether we’ll provide the care or services you request (a pre-service decision), or pay for a service you’ve already received.
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.
For information on how to request an organization determination, click on the button below.
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:
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:Health Alliance Plan
Fax: (313) 664-8045
Send us an email, or give us a call. Contact us.
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Copyright © 2019 HAP
2019 Health Alliance Plan of Michigan
Y0076_ALL 2020 HAP Website_M
CMS Accepted 9/29/2019
Last Updated 12/20/2019
Health Alliance Plan (HAP) has HMO, HMO-POS, PPO plans with Medicare contracts. HAP Empowered Duals (HMO SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.
This information is not a complete description of benefits. For more information call Medicare Michigan customer service at (800) 868-9885 (TTY: 711) 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).
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