Medical & Part C Coverage


Coverage Decisions/Organizational Determinations

What is a Coverage Decision? 

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. When a coverage decision involves your medical care, it is called an “organization determination.”

We are making a coverage decision whenever we decide what is covered for you and how much we pay. 

Examples of Coverage Decisions:

  • Your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist.
  • You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need.

In some cases, we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

How to request coverage for the medical care you want?

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. 

Call:   (877) 874-3930, TTY 711

Write: Banner – University Care Advantage

    2701 E. Elvira Road

    Tucson, AZ 85756

Fax:   (520) 874-3434

If we say "no" to your request for coverage for medical care

If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want. 

For more information on the appeal process, please visit Grievances & Appeals.


For more information on coverage decisions, appeals and complaints – please review your Evidence of Coverage booklet, Chapter 9.

 

You can ask someone to act on your behalf. Use the “Appointment of Representative” form below.

Related Documents

Appointment of Representative Form English Español