An expedited determination can be initiated if you meet two requirements:
- You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. You cannot get a fast coverage decision if your request is about payment for medical care you have already received.
- You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
Expedited Part D Drug Determinations
An expedited determination will be made within 24 hours (as opposed to 72 hours for a standard determination) if all medical documentation is provided.
How to Request an Expedited Determination
You, your appointed representative or your prescribing physician can request an expedited coverage determination for coverage if you believe that applying the standard coverage determination process could jeopardize your health. An expedited request can be submitted orally or in writing to CVS Caremark and your prescribing physician may provide oral or written support for your request for an expedited coverage determination.
- A request made or supported by your prescribing physician will be expedited if your physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
- To request an expedited coverage determination, you may:
- Call 1-855-749-0851 to speak with CVS Caremark Customer Service Representative 24 hours a day, 7 days a week. TTY: 711
- Fax a request to 1-855-633-7673 Attention: CVS Caremark Part D Services Appeals and Exceptions
- Send a written request to: CVS Caremark Part D Services Appeals and Exceptions, P.O. Box 52000 MC 109, Phoenix, AZ 85072-2000
- A request for payment of a covered prescription drug already furnished is not eligible for expedited processing.
Notification of an Expedited Request Determination
When it is determined that a request qualifies for expedited handling, the determination will be completed as expeditiously as your health condition requires but no later than 24 hours after receiving the request, or for an exceptions request upon receipt of your physician's supporting statement.
Both you and your prescribing physician will be notified of the decision, whether favorable or adverse. If you are notified of an adverse decision orally, written confirmation will be mailed to you within three (3) calendar days of the oral notification. The written notice will also state the specific reason for the denial in understandable language and contain all of the applicable Medicare appeals language to ensure you are informed of your right to file an appeal.
Please refer to your Evidence of Coverage for a complete description of the guidelines that apply to the exceptions process.
Expedited Organization Determinations (Health Care/Medical Services)
In this case, Paramount will make a determination as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.
Both you and your requesting physician will be notified of the decision, whether favorable or adverse. Paramount will notify you and your requesting physician of an adverse decision orally followed by written confirmation to you within 3 calendar days of the oral notification. The written notice will also state the specific reason for the denial in understandable language and contain all of the applicable Medicare appeals language to ensure you are informed of your right to file a re-determination (appeal).
If Paramount denies a request for an expedited organization determination, it will automatically transfer the request to the standard time frame and make a determination within 14 calendar days (the 14-day period starts when the request for an expedited determination is received by the Medicare health plan). Paramount will provide prompt oral notice of the denial including your appeal rights, and will subsequently deliver to you, within 3 calendar days, a written letter of the enrollee’s rights that:
- Explains that the organization will automatically transfer and process the request using the 14-day time frame for standard determinations;
- Informs the enrollee of the right to file an expedited grievance if he or she disagrees with the organization’s decision not to expedite the determination;
- Informs the enrollee of the right to resubmit a request for an expedited determination and that if the enrollee gets any physician’s support indicating that applying the standard time frame for making determinations could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function, the request will be expedited automatically; and
- Provides instructions about the expedited grievance process and its time frames.
How to Initiate an Organization Determination
To initiate an organization determination, have your physician complete any of the following:
- Fax prior authorization request to: Paramount’s Utilization Management staff at 419-887-2028 or toll free 866-214-2024
- E-mail prior authorization request to: Paramount’s Utilization Management staff at PHCReferralManagement@ProMedica.org
- Call Paramount’s Utilization/Case Management Department at: 419-887-2520 or toll-free 1-800-891-2520
- Providers may also submit high dollar Imaging procedures through the web-based prior authorization submission tool: McKesson Clear Coverage
- Note: Electronic or fax submission is preferred
Last updated: 09/30/2018