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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.

  • How we make determinations

    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.

  • How to request an organization determination

    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 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 within 24 hours for a Part B drug.

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

    By phone

    Call the customer service department for your plan:

    2025 Plans

    HMOs

    PPOs

    HMO-POS

    D-SNPs

    Our team members can take your call during the following times:

    • 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)

    At all other times, you may access our Interactive Voice Recording system at the same number and leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day. Please do not share personal health information when you leave your message.

    By 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

    https://www.medicare.gov/

    In writing

    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 hap.org account.
    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. Click on Register now.

    Quality of care issues

    If you’re concerned about the quality of care you received, including care during a hospital stay, you also can file a complaint with an independent organization called Livanta LLC.

    Write to or call Livanta:

    Livanta LLC
    BFCC-QIO Program
    10820 Guilford Rd., Suite 202
    Annapolis Junction, MD 20701
    1-888-524-9900
    1-888-985-8775 (TTY)
    Fax: 855-236-2423

  • Coverage determinations about prescription drug benefits

    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:

    • 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 to be 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 for prescription drugs.

    Pre-service requests for prescription drug benefits

    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
    Attn: Pharmacy Care Management

    1414 E Maple Rd.
    Troy, MI 48083

    Fax: (313) 664-8045

Health Alliance Plan (HAP) has HMO, HMO-POS, PPO plans with Medicare contracts. HAP Medicare Complete Duals (HMO D-SNP) and HAP Medicare Complete Assist (PPO D-SNP) are Medicare health plans with Medicare contracts and a contract with the Michigan Medicaid Program. Enrollment depends on contract renewals.