Determination Process

There are two kinds of organization determinations you can request if you want Alliance CompleteCare to approve a benefit or pay for a service. 

Standard Determination

You, your doctor or appointed representative may ask for a standard decision about coverage or payment of a benefit. We will give you a decision within 14 days after you or your doctor asks for it.

Expedited (Fast) Determination

You, your doctor, or your appointed representative can ask for an expedited decision if you or your doctor believes that waiting for a standard decision could cause serious harm to your health or your ability to function. We will give you a decision within 72 hours after you or your doctor asks for it--sooner if your health requires.

Drug Coverage Determinations and Exceptions

Alliance CompleteCare members have access to many common prescribed drugs. If you think that Alliance CompleteCare should cover a certain benefit or drug, you have the right to request a coverage determination or exception to our drug formulary. There are two kinds of coverage determinations you can request.

Standard Determination

You, your doctor or appointed representative may ask for a standard decision regarding prescription drug coverage or payment. We will give you a decision within 72 hours after you or your doctor asks for it.

Expedited (Fast) Determination

You, your doctor, or your appointed representative can ask for an expedited decision when you believe that waiting for a standard decision may cause serious harm to your health or your ability to function. We will give you a decision within 24 hours after you or your doctor asks for it, or sooner if your health requires it. 

 

H7292_6f CMS Approved 03072013

Last updated 03072013