As a part of Paramount Elite, you have the option to request exceptions, determinations, file grievances and appeal our decisions on your coverage.
A coverage determination is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations can also be called "coverage decisions."
Paramount has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Paramount's network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations can also be called "coverage decisions."
A grievance is a type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving.
At Paramount, we have a department dedicated to your quality care. Please take a moment to read our Quality Improvement Program Description.
Last updated: 09/30/2018