Determinations

Learn how we make decisions about coverage and payments

An organization determination is the initial decision we make about your coverage or payment for a Part B drug or medical services. A coverage determination is the initial decision we make about coverage or payment for your Part D prescription drug request.

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 7 calendar days for a standard request. If you or your doctor requests coverage for a Part B drug, we must make a decision in 72 hours for a standard request.

If you or your doctor believes that waiting 72 hours for a standard decision could seriously harm your health or ability to function, you can ask for an expedited (fast) decision. If your doctor indicates that waiting 72 hours could seriously harm your health, we will give you a decision for a Part B drug within 24 hours.

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

Phone

HMO plans

PPO plans

HMO-POS plan

D-SNP and C-SNP plans

Our customer service representatives take calls during the following times:

  • Oct. 1 - March 31 from 8 a.m. to 8 p.m., seven days a week
  • April 1 - Sept. 30 from 8 a.m. to 8 p.m., Monday through Friday

At all other times, you may access our interactive voice recording system at the same number. Leave your name and phone number, and a HAP customer service representative will return your call the next business day. Please do not share personal health information when you leave your message.

Fax

Medical Services
For new authorization requests: (313) 664-5916
For clinical information for authorizations already created: (313) 664-5701

Part B Drugs
(313) 664-8045

Through Medicare

Medicare website

Mail

Medical Services
Health Alliance Plan
ATTN: Appeal and Grievance Department
1414 E Maple Rd
Troy, MI 48083

Part B Drugs
Health Alliance Plan
ATTN: Pharmacy Care Management
1414 E Maple Rd
Troy, MI 48083

Through the Message Center

  1. Log in to your account on hap.org.

  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. Then click on Member.

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 (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 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

Pre-service requests for prescription drug benefits

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

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

Health Alliance Plan
ATTN: Pharmacy Care Management
1414 E Maple Rd
Troy, MI 48083

Fax: (313) 664-8045

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Health Alliance Plan (HAP) has HMO, HMO C-SNP, HMO-POS, and PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP), HAP Medicare Complete Assist (PPO D-SNP), and HAP CareSourceTM MI Coordinated Health (HMO D-SNP) are Medicare health plans with a Medicare contract and a contract with the Michigan Medicaid Program that provides benefits of both programs to enrollees. Enrollment depends on contract renewals.