California PHP

You can ask us to make a coverage decision, also known as an organization determination, if you are in any of the following situations:

1. You are not getting certain medical care you want, and you believe that this care is covered by the plan.
2. Our plan will not approve the medical care you doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
3. You received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
4. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

To ask that we make a coverage decision on medical care you are requesting, contact Member Services by phone, fax, or letter. If your health requires a quick response, you should ask us to make a “fast decision,” also known as an expedited determination. You, your doctor or your representative can do this for you. If you have someone asking for a coverage decision for you other than your doctor, you must submit an Appointment of Representative form authorizing this person to represent you.

We will give you a decision within 14 days after we receive your request, unless we have agreed to use the “fast” deadline, which is within 72 hours. If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

If you ask for a “fast decision” on your own, without a doctor’s support, we will decide whether your health requires that we give you a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so and we will use the standard deadline, which is within 14 days. If we say “no” to a fast decision and you are not satisfied, you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. To make a fast complaint, please contact Member Services by telephone.

If our answer is “yes” to part or all of what you requested, we must authorize or provide the medical coverage we have agreed to provide within 14 days for a standard decision or 72 hours for a “fast” decision. If our answer is “no” to part or all of what you requested, we will send you a written statement that explains why we said no.

If our answer is “no” to part or all of what you requested, you decide if you want to make an appeal. If you do, please read “Appealing a Decision We Made on a Medical Service.”

For detailed, step-by-step information about requesting a coverage decision, please see Chapter 9, Section 5 of the 2024 Evidence of Coverage, or contact Member Services. You may also contact Member Services to check on the status of your coverage decision request.

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